Director, Payor Operations

Location: This position is located at our Dublin, OH campus with hybrid flexibility.

Who we are

Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement. 

About the role

The Director of Payor Operations is responsible for the Quantum claims experience, including the effectiveness of our TPA/Payor integration & partnerships in supporting timely claims resolution for our members. The Director of Payor Operations will be responsible for leading a team of managers who are responsible for our broader payor operations team.  The Director of Payor Operations will create an environment of trust and confidence that will fully enable their team to successfully complete their job responsibilities.

 The ability to facilitate relationships, inspire collaboration, and create efficiencies with our internal claims team and TPAs are of the utmost importance in this position.  The Director of Payor Operations responsibilities will include, but not be limited to: Strategic TPA partnerships, supporting the managers with highly complex/escalated issues, TPA performance monitoring against mutually agreed upon KPIs, strategic relationship management, and overall payor operations team performance.

What you’ll do

Operational Execution

• Ensuring the broader payor operations team is meeting set KPI expectations in the following areas:
  • Claims issue research and sending to TPA
  • Member follow up and updates
  • Ultimate claims resolution
  • Management of aging claims by TPA
  • Member satisfaction – Claims process
• Partners with WFM team to manage strategic coverage taking workload fluctuation, technical challenges, and team attendance into consideration
• Serve as a strategic partner for any client-related claims escalations

TPA and Internal Partnerships

• Lead and direct discussions with potential new TPAs to review our mutual interfaces, and business needs.
• Establish and maintain TPA scorecards illustrating technical integrations, KPI measures, and partnership health for internal visibility and to serve as a baseline for strategic partnership conversations with respective TPAs.
• Solicit input from internal contacts, as well as TPA contacts, as to how interfaces are working and what additional information or changes in workflows would improve the process.
• Partner with the Quantum Professional Services team to ensure successful and seamless technical integrations for existing relationships.
• Serve as Quantum’s main tactical TPA contact and relationship owner

Team Support

• Oversees hiring strategy including leading managers though selecting, developing, and retaining top talent
• Responsible for supporting managers with complex and/or highly escalated issues
• Provide performance management coaching support through use of KPI reporting and Leadership Competencies to develop team and maximize success
• Support and model community-like culture within the team to recognize and reward innovation that improves our member and employee satisfaction
• Responsible for maintaining positive Employee Net Promoter Score (eNPS)
• All other duties as assigned.

 What you’ll bring

• 10+ years’ experience in people leadership and business operations, with a minimum of 3 years’ experience leading multi-unit operations.
• Culture champion. Creates a “best place to work” and an environment of accountability within the team.
• Confidence leading in a fast-growth, rapid change environment; enabler of growth for the organization.
• Curious, solutions-oriented servant leader, comfortable working in and achieving results in a matrixed work environment.
• Self-starter – Can translate our broader Payor Operations strategy into action and result, with little to no oversight.
• Proven success at identifying and selecting talent, and a passion for people development & coaching.
• Propensity towards complex and highly technical work
• Proven ability to cultivate, enhance, and maintain positive external relationships.
• Proven track record with change-management
• Protect and take care of our company and member’s data every day by committing to work within our company ethics and policies
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• Trustworthy and accountable behavior, capable of viewing and maintaining confidential information daily.

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