Manager, Claims

JOB SUMMARY:
The Claims Manager role is responsible for the timely payment of initial claims submissions, claim adjustments, preparation and monitoring of regulatory deliverables, staff training, professional development, policies and procedures and development of workflows, accurate processing of claims, and identifying training needs. The Claims Manager will identify root causes of payment discrepancies; perform risk assessments and effectively resolve provider payment submissions.  Identify training development needs for staff members and support coaching and champion employee engagement support. 

POSITION AREAS INCLUDED: Marketplace / Medicaid / Claims Audit / Medicare

Manager, Claims (Marketplace)

Results oriented leader responsible for managing the timely resolution of initial (front-end) claims and specified claims adjustments for marketplace. This position leads efforts to identify opportunities for continuous process improvement to improve quality outcomes by analyzing trends and identifying payment deficiencies.  The Claims Manager is responsible for collaborating with Claims Supervisors to provide strategic and operational guidance designed to improve the overall claims adjudication experience.   Manage key performance indicators to achieve established performance measures. Oversee claims inventory and workload; improve quality outcomes. Identify training opportunities. Manage all reporting requirements. Resolve escalated and complex issues.  Demonstrate experience in leading, mentoring and inspiring team members to achieve superior results.  Other duties as assigned.

JOB SPECIFICATIONS AND CORE COMPETENCIES: Marketplace
Essential Functions
Apply policy interpretation related to appropriateness and accuracy of payment practices for Medicare Advantage, Medicaid and Marketplace and Star Plus
Multi-tasker with extensive experience and judgment necessary to achieve key departmental audit initiatives
Utilize experience with various payment methodologies and contract language to assess provider billing appropriateness and claim billing practices looking for potential fraud, waste, and abuse to complete audit requirements.
Escalate quality issues to appropriate and submit timely notifications to Compliance Officers when necessary.  Create appropriate reporting of auditing statistics
Identify quality risks through auditing program and work with Operational leaders to implement appropriate strategies to mitigate risks identified. 
Compile weekly, Monthly, Quarterly, and Year to Date statistics related to Claims Audit
Marginal Functions
Perform routine and ad-hoc analysis of processes related to deficiencies identified via auditing processes.
Perform external delegation audit function (vision & dental providers) of audit program relative to claims payment


QUALIFICATIONS; COMPETENCIES; INTERPERSONAL SKILLS; WORK ENVIRONMENT
MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure:  HS or equivalent required.
Bachelor's degree preferred.

Work Experience (Years and Area):  9 years' experience to include
7 years minimum claims adjudication experience required (health plan or managed care organization)
Or
7 years minimum claims adjudication experience (health plan or managed care organization) with degree required.

Extensive knowledge of Medicare/Medicare Advantage processes and regulatory requirements preferred.
Knowledge of Medicaid and Marketplace claims processing requirements preferred.

Management Experience (Years and Area): 2 years Supervisory experience with a health plan and/or Third-Party Administrator (TPA) required.
5 years leadership experience in auditing or healthcare claim appeals, preferably with Medicare /Medicare Advantage preferred.

Software Proficiencies: Microsoft Office (Word, Excel, Outlook) required.
Other:  Strong critical thinking and analytical skills required.