Director, Claims Systems and Electronic Data Interchange

THIS IS A FULLTIME JOB : NOT A CONTRACT OPPORTUNITY

MUST LIVE OR RELOCATE TO OR, WA, ID, UT, NV, AZ

Job Summary

This position is responsible for the development and execution of the health and ongoing maintenance of our primary claims processing environment and Electronic Data Interchange (EDI) systems for all lines of business, as well as contracted services.

Work is focused on aligning ISBI resources to Client’s strategic and operational goals, developing roadmaps, vendor management, and active engagement with department leaders across the enterprise.

Primary duties include strategic, technical, and operational planning and oversight, as well as resource, relationship, and people management This position is responsible for the development of strategic plans for Claims and EDI systems with focus on modernization and reducing risk and improving maintainability of these system.

This position is also a key contributor for developing plans for the broader organization.

Essential Responsibilities

Technical / Operational Leadership

• Leads the execution of strategic initiatives, plans, and goals and advises organizational vision and goals.
• Oversees the claims system implementation function to ensure ongoing maintenance, system upgrades, expansions, architecture, and modernization.
• Oversee the EDI function to ensure ongoing maintenance, system upgrades, expansions, architecture, and modernization.
• Provides continuous evaluation of Client’s claim system(s) in support of scale, agility, and stability to meet existing and emergent organizational needs.
• Establishes and maintains an implementation team to implement near term and ongoing improvements to claims systems.
• Oversees and refines business and systems requirements for new information technologies in support of application rationalization and modernization.
• Leads innovation, process review, and improvement efforts; oversees processes and procedures to ensure compliance with regulatory bodies and statutes, including HIPPA standards for PHI protection and transmission.
• Promotes ISBI programs and staff across the organization through regular and transparent reporting, as well as publishing of short and long-term workplans.
• Provides strategic and operational leadership of IS teams in recommending, developing, and implementing internal and third-party solutions.
• Acts as project leader or sponsor on complex development programs related to Claims systems and EDI systems.

Strategic / Operational Planning

• Participates in the development of vision, goals, and strategic plans for Information Services.
• Develops short- and long-term plans and policies; oversees the development and execution of standard operating procedures.
• Provides input into the strategic plans for the organization.
• Maintains a business unit and member view while establishing department priorities, being cognizant of broader business unit and organizational impacts.

Financial / Resource Management

• Develops and manages budgets in alignment with short- and long-term plans.
• Ensures team efforts align with organization priorities in a dynamically changing environment.
• Ensures effective management of multiple internally developed and 3rd party applications critical to organizational operations.
• Partners with resource directors and managers to develop a work management and intake process.
• Approves resource allocations within budget, including people, finances, and timelines; make decisions on exceptions.

Relationship Management

• Leads effective communication system for work groups, ensuring a collaborative culture.
• Builds and ensures effective relationships across internal teams and external organizations for current or future integration.
• Partners with internal leaders and managers in identifying improvement plans and processes.
• Partners with other ISBI leaders in support of project management, release management, change management and incident management.
• Develops and maintains knowledge of Client’s critical functions in support of our members and patients; collaborates with stakeholders to understand informational requirements to support department goals.
• Represents Client within and outside the organization, providing productive leadership presence and effectiveness.

Employee Supervision

• Directs team(s) and establishes team direction and goals in alignment with the organizational mission, vision, and values.
• Identifies work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens.
• Identifies department priorities; ensures employees have information and resources to meet job expectations.
• Leads the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff.
• Manages, coaches, motivates, and guides employees; promotes employee development.
• Incorporates guidance from Client equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making.
• Ensures team adheres to department and organizational standards, policies, and procedures.
• Evaluates employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action).
• Performs supervisory tasks in collaboration with Human Resources as needed.

Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision and values.
• Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization’s strategic goals.
• Adhere to the organization’s policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and / or Education

Required

• Minimum 10 years’ relevant experience, including the following :
• Leading teams in development, support, and vendor management
• Leading teams accountable for Claims and EDI systems
• Leading teams through the re-architecture of business-critical systems
• Leading teams through cloud migration of business-critical systems
• Leading change within team and across the enterprise
• Leading and maturing a service organization in an environment of diverse stakeholders and dynamic priorities
• One or more development frameworks (Agile, Waterfall, etc.)
• Minimum 4 years' experience in a supervisory position

Preferred

• Experience with leading implementation teams for Trizetto products
• Experience with MS Azure cloud specifically utilizing Logic Apps for migrating EDI use cases to cloud
• Experience leading teams operating within a structured framework (ITSM, ITIL, etc.)
• Experience with Electronic Health Records
• Experience working in health care payer / managed care organizations
• Degree in Business, Health Sciences, or Computer Science / Engineering

Knowledge, Skills and Abilities Required

Knowledge

• Technical knowledge and leadership skills in the areas of development, support, vendor management, and program evaluation
• Sound knowledge and experience in overseeing Claims (QNXT) and EDI systems and operations
• Working knowledge with one or more development frameworks (Agile, Waterfall, etc.)
• Understanding of financial structures, fiscal responsibility, and the economic impact of business decisions
• Strong knowledge of Managed Care concepts processes preferred
• Strong understanding of Medicaid and Medicare programs preferred

Skills and Abilities

• Ability to direct and report on complex Claims and EDI solutions to internal and external leaders and partners
• Ability to inspire and direct teams in support of continuous improvement related to complex, business critical systems
• Ability to set and drive architectural direction and drive modernization of business-critical systems
• Ability to lead Cloud and on-premise architecture in support of sustainable, scalable solutions
• Ability to balance strategic and operational thinking
• Ability to effectively convey business unit goals and plans ensuring integration into strategic plans and initiatives
• Highly skilled in resource management
• Ability to develop and lead high performing team members, including hiring, goal setting, coaching, performance management, and development
• Ability to communicate effectively, both verbally and in writing, including strong presentation and change management skills
• Skilled in communicating application or product or program effectiveness at all layers of an organization (staff, leaders, and Board)
• Ability to build and maintain professional relationships with business, community, and internal management groups
30+ days ago