Description and Requirements Job Profile Summary The Director of Reimbursement Configuration is responsible for developing, directing and coordinating the configuration of claim reimbursement patterns and strategies across Healthfirst’s technology platforms in collaboration with Provider Contracting, Claims Operations, Provider Data Management, Clinical Operations, Payment Integrity, and Information Technology. The Director leads forums and meetings with leadership from across the enterprise to develop effective and efficient reimbursement configuration solutions to achieve business needs and objectives and maintain alignment with claims payment and reimbursement policies. The Director analyzes complex configuration defects and recommends strategies for successful and timely remediation. The Director leads a team of managers and analysts to ensure accurate, complete, and timely configuration of contractual terms, coding and rate updates, and fee schedule creation and maintenance. The Director oversees team performance, configuration production, and quality metrics to ensure that project and department goals are met. The Director also collaborates across other configuration teams to ensure all required configuration aspects are accounted for in planning and operationalizing accurate claim pricing and adjudication, including benefits, authorizations, reference data, claims editing, regulatory requirements, reimbursement policies, and overall claim system functionality. The Director serves as the authoritative source for all claim reimbursement patterns and payment logic across the business. Recognized as an influential leader, the individual at this level functions as a cultural ambassador and strategy driver for Healthfirst. He/she promotes and reinforces behavior that is consistent with Healthfirst’s desired culture and fulfills his/her role in aligning Healthfirst’s strategic initiatives with desired organizational outcomes. Job Description

Duties & Responsibilities:

Drive flexible, repeatable and scalable claims configuration design and implementation processes with industry best-practicesEngage directly with other operational teams and leaders to provide input on the scope, approach, and timing of configuration workAssess upstream and downstream impact of configuration and policy changes to proactively identify and mitigate riskManage interdependencies across other configuration units and business areas to ensure delivery timelines and project deadlines are metIdentify and resolve inconsistencies between system configurations and reimbursement contracts and policiesMaintain effective and consistent configuration testing protocols and quality controls Manage and monitor team performance, production and qualityEstablish structure for ongoing education, training and knowledge share across teamPrepare and present updates to the business and senior executives on configuration strategies, activities, and metricsLead and support company-wide initiativesWork with internal and external parties to ensure claim payment logic and business rules are well understood and administered appropriatelyActively support all Compliance and Regulatory requirements with appropriate policies, processes, reports, and audit support.Additional duties as assigned.   

Minimum Qualifications:

  

Bachelor's Degree from an accredited institution or equivalent work experienceProven experience in health insurance focused on claim configuration and reimbursement processesProficiency in provider contract reimbursement terms and code sets (HCPCS, ICD10, DRGs, CPT, etc.), and claims processing practicesKnowledge of medical claims and adjudication procedures, including the application of reimbursement and medical policy guidelines and contract pricingKnowledge of claim payment methodologies and regulatory frameworks governing health plan reimbursement methods in Medicare, Medicaid and commercial insurance marketsExperience leading complex, technical, cross-functional programs and working with senior executivesExperience articulating complex issues to audiences with varying levels of technical expertiseExperience influencing leaders, breaking down barriers and managing competing prioritiesStrong problem solving and analytical skillsExcellent communication and interpersonal skills

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $150,800 - $230,690

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.