Claims Manager

Nature of Work:

The professional position of Claims Manager requires an experienced, high energy, motivational leader who will effectively provide supervision, leadership, guidance and support for the Client’s Claims and Provider Relations staffs with responsibility including but not limited to claims processing, provider relations, claims editing software and all other functionality that supports the client’s Medicare and Medicaid product portfolio and administration. The manager must empower staff in meeting performance objectives and provide accurate and timely claims processing in accordance with State and Federal regulations. This position reports directly to the Director of Operations.

Essential Duties and Responsibilities:

Duties listed below may vary in terms of importance and others may be added or eliminated as this position develops.

1. Provides oversight of an operations unit that includes varying levels of employees, both salaried and hourly.

2. Provides oversight of an operations unit that includes varied products and regulatory requirements.

3. Provides high degree of oversight as it relates to improving and maintaining working relationships with client provider Network. This involves developing proactive approaches to prevent claim related issues.

4. Oversees claims staff administration activities including but not limited to pended claims processing, provider reconsiderations and appeals, member bills, coordination of benefits, adjustment processing, provider relations activities/initiatives, claims editing software and pay cycle approval.

5. Supports Provider Network Development in handling provider contract issues, maintaining positive provider relations and answering/addressing all claims/enrollment related provider questions and concerns.

6. Hires, trains, coaches and evaluates performance of direct reports.  

7. Establishes department policies and general procedures in addition to business rules and desk level procedures used by third party vendors.

8. Leads staff through change and bias for action, establishing and meeting high performance standards.

9. Audits to monitor efficiency and compliance with policies

10. Provides oversight of outside vendors to ensure compliance with contractual terms including service level agreements.

11. Develops strategies as they relate to computer systems, working with the IT Department, that ultimately assist team members to work toward achieving the goals of the project.   

12. Participates in outside audits with various regulatory agencies.

13. Prepares specialized reports or special project work consistent with the role and dictated by the needs of business.

14. Works collaboratively with the Client Finance Department in identifying and researching issues that affect Company financials and reserves.

15. Compiles, maintains and submits accurate and timely internal and external reports reflecting various department metrics, monitors results, analyzes data and makes recommendations for improvements to service levels.

16. Works effectively with internal and external customers and business partners to support client’s business strategies.

17. Operates the department within an established budget.

18. Fully participate in client’s Compliance Program, including compliance with client’s Code of Conduct, policies and procedures, and all applicable Privacy and Security laws. 

19. Performs other duties as assigned.

Required Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Requires previous management experience in the areas of health insurance, managed care programs, claims processing (preferably Medicaid and Medicare claims), and knowledge of billing codes (CPT, ICD-9, HCPCS, RUGS, CMS and DRG pricing). A combination of education, training and experience which provides the necessary knowledge, skills, and abilities as listed below will be considered.

2. Strong interpersonal skills and ability to work effectively with direct reports, peers, executive management, providers, clients, vendors, regulatory agencies and a wide variety of ethnic, cultural, and socio-economic backgrounds.

3. Ability to communicate effectively both verbally and in writing.

4. Knowledge of managed health care systems and general operational business practices.

5. Ability to effectively and satisfactorily analyze and resolve problems and issues.

6. Ability to work independently and to make independent decisions to creatively address Operations issues and assist in managing provider issues and concerns as they relate to claims processing.

7. Ability to use sound judgment in providing quality customer service to clients customers and providing accurate and timely responses to vendors.

8. Detailed knowledge of Medicaid and Medicare benefits.

9. Understand the overall impacts of claims processing to the company financials

10. Knowledge of compliance implications that may impact the organization.

11. Ability to maintain strict confidentiality.

12. Word processing and spreadsheet skills. (Word and Excel preferred).

All your information will be kept confidential according to EEO guidelines.