Manager, Claims Operations

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Requirements:

• Minimum 3 - 5 years’ experience in Management of a claim operations.
• Demonstrated skill in managing change and in team building
• Advanced knowledge of claims processing including deep knowledge of claims data analysis, and the setting, tracking and reporting on performance metrics.
• Proficient with Microsoft applications, Excel, Word, Access and Power Point.
• Experience with HMO Medical insurance claims with in-depth understanding of federal and state regulations.
• Demonstrated skill in problem solving, exercising initiative, and decision-making within scope of role.
• Thorough understanding of claims processing compliance requirements.
• Ability to meet deadlines and prioritize tasks and assign work daily to the staff.
• Demonstrated project management experience.
• Ability to work independently with minimal supervision.
• Exceptional judgement in escalating concerns to next level leadership.
• Exceptional written, visual and verbal communication is necessary to lead a team and convey clear instruction.
• Change management skills are necessary in order to engage a team as we grow.
• Continuous improvement and a growth mindset are required.
• Claim coding experience, coding edits experience.
• CPT and ICD coding knowledge and medical terminology

Responsibilities:

• Responsible for the day-to-day management of the Claim Operations team.
• Maintains and improves claims processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans.
• Assessing and assigning workflow, coaching, counseling.
• Use reporting data analytics to track KPIs and report to leadership on a daily, weekly, monthly basis.
• Monitor individual Analysts quality and production measures, conducting staff performance conversations, monthly 1:1’s with individual staff to review their concerns, give feedback, mentor goals and career progression.
• Responsible for writing and maintaining desktop procedures for claims processing functions.
• Identify areas within the claims workflow and system tools where the processes can be improved/enhanced, analyzing current workflows, designing and implementing changes to streamline operations and monitor the impact of those changes to ensure increased efficiency and production.
• Leveraging technological advantages and incorporating new workflows to scale the business.
• Responsible for the distribution and completion of assigned JIRA tickets relating to claims inquiries or adjustments requests.
• Complete first round of claims processing reviews on client reporting requirements prior to sending for their approval.
• Coordinate operational workflows and other internal functions alongside departments and managers.
• Participate in the Monthly Policy and Procedure committee meetings, complete review of policies to approve or suggestions for updates.
• Conduct at minimum monthly team meetings, and attend operational meetings as requested.