Medical Claims Manager 5/6/2020
JOB DESCRIPTIONAPPLY The Claims Manager manages the Claims Department composed of Claims Resolution Specialists, Adjustment Examiner, Appeals Examiner, Data Entry Technician, and Mailroom Sorter. This role resolves outstanding issues and provides guidance to specialists in a variety of duties.
What you will do:
* Operate one or more claims processing units, including the timely and proper disposition of claims in accordance with coverage unit.
* Research claim issues to identify root causes and determine corrective actions to resolve issues, communicate findings, and document findings for future use.
* Request additional information needed to complete adjudication of claims.
* Review claims for necessity, limitations, and exclusions based on claim policies and procedures.
* Identify reoccurring problems and providing feedback to management to affect change.
* Familiarity with medical bill forms, ICD-9/10CM coding, CPT coding, bill forms, and other medical coding schemes.
* Assist internal associates with claim-related questions and issues.
* Identify reoccurring problems and provide feedback to management to affect change.
* Ensure appropriate payment adjustments are entered into the claims system.
* Ensure accuracy of data entry for tracking and reporting of claim disputes.
* Manage sensitive data in accordance with HIPAA and Medicaid regulations.
* Act as a trouble-shooter to resolve claim processing problems among internal departments, including authorization issues.
* Assist in providing daily guidance for associates to obtain optimal results and to ensure all SLA and timeliness standard are met.
* Handle all types of requests, inquiries and complaints accurately and timely.
* Monitor team members daily productivity goals and provide feedback where necessary.
* Provide re-enforcement training for new and existing associates as needed.
* Help identify system/benefit errors completing protocols and workflows to prevent future errors.
* Complete performance reviews and staff coaching.
* Provide ongoing training with staff.
* Ability to manage and motivate staff.
* Ensure Service Level Agreements (SLAs) are met.
* Ability to work and communicate effectively with internal and external stakeholders.
* Monitor and develop reports to ensure staff are meeting individual performance standards.
* Knowledgeable in medical terminology.
* Analyze and report current and historical statistical within the practice.
* Ability to simultaneously maneuver through various computer claims and eligibility platforms while verifying information while on the telephone.
Who you are:
* Must have a BS/BA degree in Healthcare, Business, or other related scientific or technical discipline, with recent experience of at least Five (5) years in medical bill processing or similar environment.
* Three (3) years of that experience in claims resolution and adjustment conducting claim-specific research to resolve outstanding issues (may overlap with other experience).
* One (1) year of that experience in a leadership role managing resolution and adjustment specialists that conduct bill-specific research to resolve outstanding issues (may overlap with other experience).
* OR, High School or GED equivalent diploma, with recent experience of at least: five (5) years in medical bill processing or similar environment.
* Three (3) years of that experience in Resolution and Adjustment, conducting claim-specific research to resolve outstanding issues.
* General knowledge of medical terminology.
* Familiarity with medical bill forms, ICD-9/10CM coding, CPT coding, bill forms, and other medical coding schemes (certificate desired).
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor s legal duty to furnish information. 41 CFR 60-1.35(c)