Sr. Claims Manager

[Confidential] We are a healthcare company has a contract with the Center of Medicaid and Medicare Services (CMS) and an MAPD plan for 2024. We are looking for a Senior Claims Manager to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Our health plan is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with us and we will support you all the way.

Position Overview

The Senior Claims Manager will own the prepayment identification of claim adjustments, Payer Compass claims testing as well as corrections for EDPS encounters. The incumbent will execute pre/post claims editing, audit, EDPS and claim adjudication programs that will drive incremental value year over year.

Senior Claims Manager will continually identify savings opportunities, develop mitigation strategies to avoid future overpayments/underpayments, and implement plans to achieve overall business goals.

Job Description

• Establish a stellar claims team capable of proactively identifying and investigating payment issues and working with key stakeholders to develop mitigation strategies to prevent future occurrences, with ability to review impacts holistically.
• Proven track record in claims processing and EDPS.
• Develop and deploy mitigation strategies to avoid future overpayments and drive incremental value year over year in both medical and administrative cost savings.
• Assists in EDPS configuration issues and loading of provider information, as needed.
• Develop and monitor a strong high-dollar claim review program.
• Research and resolve claim/ issues, pended claims and update system as appropriate.
• Lead and manage the most problematic and complex audit assignments to identify incorrect claim payments in accordance with established billing and coding parameters.
• Serve on workgroups to develop new initiatives that have impact on reimbursement to ensure that any new procedures or policies are consistent with overall corporate business objectives and can be implemented cost-effectively ensuring payment accuracy.
• Ability to travel
  
  
  

Minimum Qualifications

• Bachelor's degree preferred in Computer Science, Healthcare Administration, or related field
• 5+ years’ experience in configuration/benefits and/or medical claims processing.
• Experience with bundled payment contracting or risk and capitation required
• Experience with Payer Compass Optimization.
  
  
  

Professional Competencies

• Proficient in Microsoft Suite (Excel, PowerPoint, Project, Outlook, Word, Visio, etc.)
• Extensive experience in SQL
• Experience with the end-to-end claims processing
• Knowledge of medical terminology, ICD-10, CPT and HCPCS.
• Understand all relevant payment methodologies, including but not limited to Medicare, RBRVS, DRG, APR-DRG, MS-DRG, OPPS, Per Diems, Capitation, and Case Rates.
• Strong analytical skills with the ability to collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.
• Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation.
• Understands how to build/maintain Benefit Rules & Benefit Records (Detail Option Records).
• Ability to manage and prioritize multiple tasks, promote teamwork and fact-based decision making
• Ability to work independently and within a team environment
• Critical listening and thinking skills
• Decision making/problem solving skills
• Resiliency in a changing environment
• Demonstrated progression of leadership and responsibility
• Ability to work in a fast-paced, start-up culture
• Proven ability to build, develop, and lead strong teams of operators
• Preferred Certified Medical Reimbursement Specialist certification via AMBA
  
  
  

Supervisory Responsibilities. This job has no direct supervisory responsibilities but will be required to perform as a team leader and act as a backup for the Vice President of Claims.

We care deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time

Benefits:

• 401(k)
• Dental Insurance
• Health insurance
• Life insurance
• Paid time off.
• Vision insurance
  
  
  

Schedule:

• 8-hour shift
• Monday to Friday/Weekends as needed
  
  
  

Ability to commute/relocate:

• Reliably commute or planning to relocate before starting work (Required)
  
  
  

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

• Other duties may be assigned in support of departmental goals.