Manager of Claims

The Manager of Claims is responsible for managing the operational performance of the claims area to ensure production and quality standards are achieved and are in line with the Plan’s strategic goals. This includes responding to related interdepartmental requests, and providing analytical and reporting support related to claims operations. The Manager is responsible for developing policies and procedures, workflows, maintaining claim payment quality and identifying training needs for staff. The claims manager will participates with other members of management to discuss, develop and implement operational and organizational processes that improve efficiency.

Key Functions/Responsibilities:
– Responsible for day-to-day management of the Claims Department function.
– Manages staff development, work standards and recruits, motivates and retains a high caliber team to ensure efficient operation of all claims functions.
– Collaborates with training and quality resources to provide on-going training for staff which includes performance coaching.
– Establishes and maintains standards of performance for productivity, quality and claims turnaround. Adjusts such standards when necessary due to processing system enhancements, streamlined workflows or other production efficiencies.
– Provides feedback, suggestions, status updates to department leaders regarding improvement initiatives and opportunities. Provides input into development of the department budget and manages and controls expenses while meeting operations requirements.
– Monitors relevant daily and weekly claims status reports, levels of service, transaction receipts, productivity, and quality to identify performance gaps. Takes corrective action and follows up to ensure positive outcomes and goals are achieved.
– Develops and documents workflows, business policies, practices and procedures to ensure quality and consistency.
– As appropriate and/or assigned, the claims manage is responsible for the preparation and research of data and records as well as associated reports required to meet internal and external audit and regulatory requirements.
– Communicates details and provides examples of provider billing problems, contracting, coding, member and IT issues to the appropriate departments in a timely fashion and works with these organizations to resolve such issues.
– Coordinates resources to ensure that projects have sufficient means to meet/exceed Maintains and attends regular meeting scheduled with other functional departments to identify any processing system issues that negatively impact claims productivity and/or quality, review procedures, and resolve issues. Ensures that all IT system changes that affect service levels and processing are thoroughly tested before being incorporated into the live environment.
– Obtains and maintains a complete understanding of the Facets system.
– Maintains current knowledge of provider network development and contract issues, Massachusetts Medicaid regulations, as well as industry standards for claims adjudication issues. Ensures that these issues are captured in training and reference materials as well as policy & procedure documents.
– Expected to take on and complete any other assignments outside of the regular duties for this position when assigned by management.

Qualifications:

Education:
– Bachelor’s degree or the equivalent combination of training and experience, usually 6-7 years related experience in a managed care plan is required.

Experience:
– Minimum of 3 years of claims experience required.
– Minimum of 5 years of experience at the supervisor and/or manager level.
– Minimum of 5 years of experience working for a managed care plan required.
– Facets experience is strongly preferred.
– Medicaid experience preferred.
– Claims billing experience working for a provider is preferred.
– Some knowledge of CMS regulations preferred.

Competencies, Skills, and Attributes:
– Detail oriented, organized, and possesses demonstrated leadership skills along with excellent verbal and written communication skills.
– Ability to apply independent and critical thinking to solve complex problems.
– Excellent interpersonal skills are required to effectively develop and maintain strong working relationships with internal and external colleagues.
– Proficiency in the use of Microsoft office products such as Word, Excel, PowerPoint and Outlook required. Experience with Facets highly desirable.
– Working knowledge of claims processing systems, CPT-4 and ICD-9 coding, and relevant MassHealth regulations.
– Ability to multi-task, prioritize and work independently.
– Ability to initiate and drive change; demonstrated results-driven approach.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

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