Job Summary:
Responsible for the day-to-day oversight of the Claims Operations department. The position will collaborate with the Director of Claims to implement short- and long-range goals, coordination of claims operations staff, enhancement of claims business development efforts and a continues focus on optimization around automation, compliance, quality, and reporting. The Claims Manager is responsible for ensuring compliance with company policies, procedures, State and Federal regulatory requirements for all claims operations under their management. This position works closely with IT to identify opportunities for innovation and operationalization of innovative ideas.
Essential Job Functions:
Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the position.
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Manages the claims production, provider dispute resolutions, eligibility, claim customer service and recovery unit to meet regulatory timely and quality requirements.
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Manages the claims training unit that includes training curriculum, desk level procedures, training schedules, and refresher training.
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Manages staff productivity, attendance and quality and addresses any deficiencies in a timely manner.
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Improve claims processes to gain operational efficiency while ensuring compliance with lines of business and state-specific requirements.
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Generate, monitor, and communicate all inventory to the Claims Director daily including action plans to meet timeliness for each weekly check write.
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Oversee internal processes between the claims department and other internal departments.
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Ensuring staff are proficient in the use and understanding of claims guidelines and monitors consistent application of claims policies and procedures.
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Maintaining, reviewing, and updating policies and procedures in relation to claims in response to regulatory and business updates and communicating revisions to the appropriate staff on an annual and as needed basis.
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Report any core system issues or concerns.
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Execute activities by leading interdisciplinary workgroups in analyzing, planning, and implementing programs, processes, and workflows. Effectively facilitates teams and manages relationships
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Respond to escalated provider inquiries.
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Developing claims reports to measure and improve operational effectiveness.
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Communicate claims operational issues to the leadership team.
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Develop project work plans by defining tasks, setting deadlines, assigning responsibilities, and procuring resources.
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Drives change initiatives to address future-oriented business needs.
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Provides an environment which fosters continuous quality improvement of claims.
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Lead the team by demonstrating corporate values including continual learning and improvement.
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Participates in the recruitment, training and development of claims staff which would include coaching, counseling, and evaluating performance of direct reports.
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Follow company policies and procedures and conduct annual performance reviews in a timely manner.
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Serves as a subject matter expert for other areas of the company as well as within the department.
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Respect and maintain HIPAA confidentiality guidelines.
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Acts with honor and integrity, serving as a role model for the company.
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Performs other duties as assigned.
Other Functions:
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Enforces Company policies and safety procedures.
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Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
Competencies
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One (1) year in a managerial role in addition to two (2) years’ related experience.
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At least five (5) years of healthcare claims experience, which includes all aspects of claims administration.
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Two (2) years Medi-Cal claims experience.
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Managed care experience preferred.
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Demonstrated success leading teams of direct reports in a metrics-driven environment.
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In-depth knowledge of regulations and procedures governing Medi-Cal and other state sponsored programs.
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In-depth knowledge of procedure coding and medical terminology, and their application in benefits; general medical policy benefits and exclusions, and industry standard payment practices.
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Ability to read, interpret and apply complex written guidelines, instructions, and other materials.
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In-depth knowledge of claims processing systems.
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In-depth of audit processes, and the ability to effectively implement and maintain them.
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Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff.
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Intermediate skills in Word and Excel, including the ability to including the ability to develop formulas and links.
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Excellent communication skills, including both oral and written.
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Excellent active listening and critical thinking skills.
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Ability to solve mid-level problems with minimal supervision.
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Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers.
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Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
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Demonstrated excellence in project management and organization.
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Ability to provide and receive constructive job and/or industry related feedback.
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Ability to maintain confidentiality and appropriately share information on a need-to-know basis.
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Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
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Ability to consistently deliver excellent customer service.
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Excellent mindfulness and ability to document information accurately
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Ability to work in a dynamic, fast-paced team environment and achieve objectives effectively and positively.
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Demonstrate commitment to the organization’s mission
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Must have the ability to quickly learn and use new software tools
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Must have mid-level skills using e-mail applications
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Initiative-taking with strong organizational, multi-tasking, planning, and follow up skills.
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Ability to work independently as well as in a team environment.
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Ability to present self in a professional manner and represent the Company image.
Supervisor Responsibility
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This position supervises up to 5 employees in exempt positions.
Education and Licensure
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High School Diploma or GED required.
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BA/BS in Business or related field preferred.
Travel
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The incumbent may travel up to 5% of the time.
Work Environment
This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.