Claims Manager

Description

We are seeking a detailed-oriented and experienced Claims Manager to join our Claims leadership team. In this key role, you will oversee a dedicated team of claims examiners, auditors, and support staff, and monitor the department for regulatory compliance. You will be responsible for implementing and maintaining efficient claims adjudication processes that utilize technology to automate workflows and maximize the accuracy of claim payments.

The ideal candidate will demonstrate strong leadership and communication skills, fostering collaborative relationships with colleagues and team members. You will promote high-quality customer service and identify opportunities for workflow improvements to boost effectiveness and productivity. Additionally, you will research and resolve complex claims issues and develop standard operating procedures for handling various intricate claim scenarios.

Salary Range: $92,600 - $202,200 Annually

Qualifications

1. High School Diploma required
2. Bachelor’s Degree in Business Administration, Health Care or other related field preferred or equivalent work experience, preferred
3. 5 years previous experience in claims operations specifically related to Medicare Advantage or managed care in a complex and diversified healthcare or health insurance company
4. 3 years experience managing personnel with at least 2 years managing personnel in a claims processing environment
5. Extensive knowledge of physician and facility billing practices, appropriate CPT coding initiatives, ICD-10 coding standards related to specificity, as well as Revenue and HCPCS coding
6. Strong working knowledge of provider network/IPA arrangements and reimbursement methodologies and of health benefit plan concepts
7. Conversant with standard electronic and paper claim formats; familiarity with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) coding guidelines such as the National Correct Coding Initiative (NCCI) edits and their relation to clinical logic in claims adjudication
8. Experience with Microsoft Office Suite (Excel, Word, and PowerPoint) and data visualization tools
9. Strong knowledge of all regulatory standards such as HIPAA, DMHC, AB1455, and CMS reporting requirements
10. Familiarity with claims edit software
11. Ability to analyze and organize complex federal and private insurance regulations
12. Strong critical thinking and the ability to apply knowledge at a broad level within a complex academic medical center is essential
13. Ability to support the working hours of the department
14. Ability to travel/attend off-site meetings and conferences