This position is responsible for providing claims leadership to the claims department with an emphasis on claims productivity, quality and accuracy. Responsible for the direction of the day to day workflow within the Claims Department including management of personnel and the monitoring of production and quality standards.
Responsible for meeting all of the MCS Job Standards described below. Overall accountability for ensuring the design and development of claims workflow, policies and procedures as well as make appropriate recommendations that will positively impact operational effectiveness. Responsible for meeting and exceeding operational productivity standards and for ensuring that claims are processed within the timeliness guidelines, while ensuring accuracy and quality. Ensure proper utilization of human and system resources to achieve stated performance objectives for productivity, quality, data integrity and financial controls within budgetary constraints. Provides assistance to senior management in the implementation of new business objectives and the completion of the QNXT migration. Participate in organizational planning, including development and revision of action plans and outcomes evaluation as appropriate. Responsible for a full range of activities which ensure the operational effectiveness and excellence of the claims department as a whole. Must work in conjunction with other departments to achieve business objectives and resolve issues. Ensures financial objectives and controls are satisfied regarding distribution of claim payment checks and support documentation. Works with senior management on the development of the annual budget. Meets with external clients, providers, and/or employers to address claim related issues (i.e., Joint Operation Committee meetings with contracted health plans, quarterly provider meetings, workshops, etc.) Performs other duties as assigned.
Thorough knowledge of claims payment principles, policies and coding structure required (ICD-9/10, CPT, HCPCS, and revenue codes).
Ability to communicate orally and in writing in a professional and diplomatic manner.
Ability to set and meet priorities and deadlines.
Demonstrated knowledge of fiduciary responsibilities, laws, rules and regulations as defined under state statutes, the Department of Corporations, and the Health Care Finance Administration.
Must work collaboratively at all levels of the organization to ensure quality outcomes.
Excellent understanding of claims regulatory requirements including but not limited to AB1455, Commercial and Medicare TAT requirements, COB and clinical editing.
Understands fully the claims process flow and functionality of the core system for both EZ Cap and QNXT. Can provide leadership and direction to the claims staff to ensure quick problem resolution.
Must be able to read and interpret claims management reports such as, TAT, inventory and productivity reports.
5 years of healthcare claims adjudication; medium to high complexity.
5 years of experience in medical billing and collections in healthcare setting.
5 or more years in a supervisory/managerial position.
Experience managing a team of 10 or more.
Bachelor’s degree or 5 years of related job or industry related experience in lieu of degree
Health plan adjudication experience.
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