Claims Manager

The Claims Manager is responsible for overseeing and directing delegated Managed Care Claims adjudication and manage our medical claims department.

Essential Job Duties & Responsibilities

• Participate in inter-departmental business activities, including input into budget preparation
• Prepare inbound and outbound 835, 837, EFT, etc.
• Encourage positive staff results by communicating job expectations; planning, monitoring, and appraising results; coaching, counseling, and implementing corrective action plans when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards.
• Complete performance evaluations in a timely manner.
• Create, review, and/or update departmental procedures, workflows, and resource material.
• Implement necessary policy and regulatory changes.
• Develop and manage auditing and quality control standards.
• Supervise the coordination of workflow and staffing of day-to-day activities as well as assigning and monitoring work of staff in order to adhere to productivity and quality standards to meet stated goals.
• Manage delegated claims audit and reporting.
• Ensure CMS and delegated claims compliance.
• Resolve and/or gather appropriate guidance for any escalated issues.
• Other duties, as assigned

Experience

• Minimum 5 years medical claims adjudication working experience, with at least 3 years of managerial experience
• Medicare guidelines and healthcare claims regulation knowledge
• Delegated Medicare Advantage Experience is required
• Experience with claims adjudication software

Education

• Bachelor’s Degree preferred. In lieu of a degree, 6 or more years of relevant experience

Knowledge, Skills & Abilities

• Medicare guidelines and healthcare claims regulation knowledge

Work Hours, Travel Requirements

• Monday – Friday, 8:00 a.m. – 5:00 p.m., and as needed to complete projects.
• Travel to medical offices may be necessary for the purpose of providing benefit education.