Director, HMO Claims Services

This is a full-time leadership position, eligible for Scripps Health annual Management Incentive Compensation Plan. This position is partial remote and located in San Diego and does require residence in San Diego. The weekly schedule will be 2 days in the office and 3 days remote.

Join the Scripps Health team and work alongside passionate caregivers and provide patient-centered healthcare. Receive endless appreciation while you build a rewarding career with one of the most respected healthcare organizations nationwide.

The Director of HMO Payment (Claims) Services for Scripps Health Plan leads the claims payment team and ensures accurate and timely payment of provider and institutional claims. The candidate will manage successful Plan and DMHC Audit performance, staff education and training, and manage the PDR process. This individual will interface with all MSO and Plan departments to ensure proper workflow and serve as SME for IS implementations and reporting.

(This is not a revenue cycle - claims billing position)

Successful candidate will demonstrate:

• Claims automation optimization.
• Claims recovery.
• Epic/Tapestry expertise including workbench and WebI reporting.
• Reporting and KPI development and management.
• Experience with mailroom.

Required Education/Experience/Specialized Skills:

• 8 years’ experience in managed care claims, 3 of which in leadership.
• Expertise in California DMHC claims regulations, NCQA regulations, and health plan experience.
• Strong technical aptitude for computer systems and databases.

Preferred Education/Experience/Specialized Skills/Certification:

• Bachelor’s degree in related field.
• Epic Tapestry experience.
• Strong reporting experience, specifically Epic Workbench and WebI.
• Understanding of institutional and professional claims, implications, and codes.
• Experience with DMHC audits, health plan audits, CPT and ENM coding.
• Mailroom experience.