Director Third Party Liability (Coordination of Benefits & Subrogation)

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Director of Third Party Liability (TPL) provides leadership, direction, and subject matter expertise for all aspects of third party liability claims, which include Coordination of Benefits with other health insurance companies and Subrogation for accident and injury claims. The Director is responsible for the teams, systems, and processes that support that goal, which include any suppliers that provide these services to the health plan. The TPL programs include the scope of both the health plan and the claims as processed by its delegated suppliers (e.g. Pharmacy, DME, vision, dental, behavioral health). The Director leads the strategy, implementation, and oversight of programs that assure that member and provider payments are appropriate and accurately reflect state and federal requirements and internal policies and procedures.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Designs, implements and monitors comprehensive Third Party Liability strategies to ensure that WellSense Coordination of Benefit and Subrogation programs perform at the highest level of operational excellence.

* Aligns TPL strategy with overall company objectives and regulatory requirements.

* Serves as WellSense's Third Party Liability subject matter expert, providing insights and recommendations to support strategic decision making at the executive level.

* Leads and manages the Coordination of Benefits and Subrogation teams, providing guidance, goal setting, support, and professional development.

* Manages the financial performance of the Third Party Liability teams to achieve annual corporate financial targets.

* Acts as the designated Third Party Liability Coordinator in the New Hampshire Medicaid state contract.

* Fosters strong relationships with healthcare providers, vendors, attorneys and regulatory bodies to ensure transparency, compliance, and efficient resolution of payment related issues.

* Work closely with internal departments and executive leadership including compliance, legal, finance, claims, provider network, and IT to ensure alignment and integration of TPL programs and initiatives.

* Collaborates with legal counsel to manage litigation and negotiate settlements.

* Drives continued improvement in the department's benefit/cost ratio to maximize value of investments in staff, technology, and supplier contracts.

* Ensures compliance with federal, state, and local regulations related to health insurance payment processes.

* Creates incentives and programmatic structure to continually drive process improvements and efficiencies.

* Ensures the timely and effective handling of claims in accordance with service level agreement requirements.

* Ensures department policies and procedures are maintained at the highest level of quality and accuracy and that claim handling practices are followed to provide a consistent approach to managing claims.

* Develops, implements, and maintains new policies and procedures related to TPL claims and associated operational processes as needed.

* Implement best practices and innovative solutions to enhance TPL programs.

* Monitors and reports on key risk indicators related to TPL within the organization and additionally within the health insurance industry.

* Works directly with providers, health plans and attorneys to resolve critical issues and provide education on persistent concerns.

* Consolidates validated financial value data from various sources to enable reporting, trend analysis, benchmarking, and forecasting in support of strategic decisions.

* Stays informed about best practices and emerging trends through engagement with external partners such as auditors, regulatory agencies, and industry groups.

* Leverages advanced analytics, artificial intelligence, and machine learning tools to enhance financial and operational efforts.

* Ensures the effective use of technology to monitor, detect, and prevent payment errors.

* Develops and delivers enterprise education on TPL programs and practices.

* Oversees the design, development, automation, and maintenance of dashboards that demonstrate TPL value delivery based on performance trends, opportunity analyses, and market-based benchmarks.

* Prepares and delivers clear, concise, and actionable reports and presentations to executive leadership.

* Communicates TPL strategies, outcomes, and risks to senior executives.

* Oversees department cost center, including budgeting, financial planning, and resource allocation.

* Represents the health plan in person at industry events, trainings, and on-sites with contracted suppliers

* Fosters a culture of integrity, accountability, and continuous improvement within the team.

* Other duties as assigned

Supervision Exercised:

* 3-5 Direct FTEs, Department of 25-30 FTEs

Supervision Received:

* Weekly supervision through meetings with manager and regular written communication

Qualifications:

Education Required:

* Bachelors Degree in Business Administration, Health Administration, Law, or a related field, or the equivalent combination of training and experience

Education Preferred:

* Masters Degree in Business Administration

Experience Required:

* Minimum of 10 years of related experience with Third Party Liability (TPL)/Other Party Liability (OPL)

* Minimum of 5 years of prior TPL/OPL team management experience

* Experience working directly with the C-suite/VP level on a regular basis.

* Experience working directly with health providers

* Knowledge of Medicaid and Medicare plan concepts, principles, practices, operations and requirements.

* Experience evaluating and implementing solutions from outside suppliers

* Deep subject matter expertise in the rules and regulations pertaining to Coordination of Benefits and Subrogation

Experience Preferred/Desirable:

* Healthcare claims management

Required Licensure, Certification or Conditions of Employment:

* Professional coding certifications preferred

* Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

* Ability to track, prioritize, and drive multiple concurrent projects to success.

* Flexibility to adapt and manage assignments as they evolve in a dynamic environment.

* Excellent communicator in written and verbal form; ability to work well with executives, and to lead and influence across multiple levels and multiple functions of an organization.

* Entrepreneurial, with skill in navigating ambiguity and complexity.

* Strong ability to influence and collaborate. Comfortable providing strategic advice to senior leadership.

* Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation

* Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes.

* Highly capable with Excel and other Microsoft Office tools

Working Conditions and Physical Effort:

* Work is normally performed in a typical interior/office work environment.

* No or very limited physical effort required. No or very limited exposure to physical risk.

* Occasional travel 2-4 times a year to business meetings and conferences

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees