Manager, Claims Operations
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POST DATE 8/12/2016
END DATE 11/6/2016
University of California - Los Angeles Medical Centers
Los Angeles, CA
JOB DESCRIPTIONJob Title:
Manager, Claims Operations
9:00a to 5:30p M-F
$36.88 / $6417
$71.84 / $12500
Layoff Referral Deadline:
The Manager, Claims Operations is responsible for the planning, development and implementation of administrative and operational Claims functions in adjudicating FFS and Capitated claims for authorized services, timely, accurately and consistent with member benefits and in compliance with contractual, State and Federal regulations. The incumbent will implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments. The Manager will establish methods for continuous monitoring/auditing of workflows to ensure the integrity and goals of the processes remain consistent and to identify potential opportunities for improvement. The Claims Operations Manager is accountable for the oversight and coordination of the following major functions: Claims Operations Program, Coordination of Benefits, Appeals and Overpayment Recoveries, Audit/Quality Control, Claims Edit Business Rules/Configuration, Retrospective Review, Customer Service, Claims Mailroom
High school diploma required
Bachelor s degree in healthcare administration, business administration, or a related field preferred.
Minimum of five (5) years previous experience in claims operations specifically related to managed care in a complex and diversified healthcare or health insurance company.
Minimum of three (3) years experience managing personnel with at least two (2) years managing personnel in a claims processing environment.
Strong working knowledge of provider network/IPA arrangements and reimbursement methodologies and of health benefit plan concepts such as limitations, exclusions, carve-outs, coordination of benefits, benefit accumulators, member and plan responsibilities,, authorization requirements, recoveries, and the appeals process.
Must have extensive knowledge of physician and facility billing practices, appropriate CPT coding initiatives, ICD-9/ICD-10 coding standards related to specificity, as well as Revenue and HCPCS coding.
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
Must be familiar with all regulatory standards such as HIPAA, DMHC, AB1455, and CMS reporting requirements. Demonstrated computer skills; proficient with Microsoft Windows applications including but not limited to Excel, Word and Outlook as well as ability to conduct Internet based research
Familiarity with Microsoft Access and/or SQL a plus.
Extensive knowledge of one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXT.
Familiarity with claims edit software i.e. Optum CES, McKesson etc.
Sound and independent judgement and the ability to think and conceptualize beyond existing barriers, methods and practices.
Strong leadership skills, with the ability to articulate goals, plan and implement processes to achieve those goals, recognize and assess the implications of confounding variables, anticipate consequences, and meet deadlines.
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardizations exist.
Effective oral, written communication and presentation skills sufficient to communicate clearly and grammatically both complex and simple messages to a wide audience either within or outside of the organization
Detail-oriented without losing sight of broader perspectives.
Ability to travel/attend off-site meetings and conferences.