Your Future Evolves Here
Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving power that brings us to work each day. We believe in embracing new ideas, testing ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.
Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign's Corporate Equality Index; was named on the Best Companies for Women to Advance List 2020 by Parity.org; and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.
True Health New Mexico merged with Evolent Health on January 1, 2018 and, as an Evolent company, continues to focus on improving the health and well-being of its health plan members by making sure their care is coordinated at every level. Within the Evolent ecosystem of provider-centric solutions for value-based care, our True Health New Mexico team focuses on keeping people healthy, lowering premium costs, and delivering appropriate levels of care at the right time to help health plan members avoid unnecessary hospital stays and emergency department visits. True Health New Mexico serves individuals, small and large businesses, and federal employees across New Mexico. Together, Evolent and True Health New Mexico are harnessing the power of our combined organizations to improve the health of New Mexico. Join the True Health New Mexico team and put your passion to work for transforming the U.S. health care landscape for patients, providers, and payers.
Who You’ll Be Working With:
You will work on the Operations Team. You will report to the Chief Operating Officer and work closely with the Senior Director of Operations, the Senior Director of Sales and Account Services, the Director of Provider Services, Director of Appeal & Grievance, and the Director of Enrollment and Customer Service.
What You’ll Be Doing:
The Director of Claims is responsible for developing and implementing workflows between the local market and Health Plan Services (HPS). This position is responsible for managing staff, managing external relationships with vendors, and ensuring the Company provides an exceptional level of service to our members and contracted providers.
- Manages oversight of administrative operations of the Claims and Compliance function performed by HPS.
- Develops, implements, and monitors claims measurement standards and establishes goals and quality standards.
- Promotes coordination between Provider Services Department and HPS claims.
- Supports programmatic development of policies and procedures and workflows to ensure they are optimally designed to adhere with state and federal requirements.
- Provides support to staff; investigates and resolves complex issues.
- Participates and provides strategic input on claims strategies to support optimal performance standards for the Company.
- Participates with internal and external vendors regarding claim, benefit, and configuration audits.
- Responsible for post implementation oversight and audit functions for benefit and contract configuration.
- Participates in appropriate meetings with health consumer operated and oriented health plans (CO-OPs) at federal, state, and local levels, to ensure local market is conveying and managing customer needs to HPS.
- Oversees weekly claims runs to ensure the Company is properly reimbursing providers and facilities for services rendered to members.
- Other duties as assigned.
The Experience You’ll Need (Required):
- At least 5 years of claims experience at the supervisor level.
- Detailed knowledge of managed care and commercial claims and enrollment processes.
- Ability to lead claims development and meet deadlines.
- Ability to identify and implement program changes as necessary.
- Ability to communicate and manage contracted business partners.
- Expertise with Microsoft Office Word, Excel, and Outlook.
- Energized by and comfortable with rapidly evolving organizational needs and environment.
- Bachelor’s degree from an accredited college or university. May be able to substitute experience for degree.
Finishing Touches (Preferred):
- Experience in the New Mexico health insurance market.
- Bilingual speaking, writing, and reading skills.
Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.