Job Summary:
The Manager, Claims Performance Solutions oversees and optimizes the claims process by analyzing data, identifying areas for improvement, implementing strategic solutions, and leading teams to achieve high performance standards in claims handling, ensuring efficient and customer-centric claim resolution while adhering to company policies and regulatory requirements. Team functions include proactive claim adjustment processes and oversight, data analysis, third party liability and direct billing, regulatory reporting, member/provider communications, data governance, and denial management.
Essential Functions:
- Provide expertise to team and departments in regards to claim adjustments, process automation, claim payment system, root cause analysis, and process development
- Oversee and lead research of analysis of data in relation to claim adjustments and to draw conclusions to resolve issues as it relates to claim payments, denial, Facets payment methodology, and clinical edits
- Responsible for understanding industry advancements in claims processing and automation and identifying opportunities to leverage efficiencies for claim adjustments Lead operational opportunities and recommendations for automation and process improvements
- Review and analyze the effectiveness and efficiency of existing claims processes and systems, and participate in development of solutions to improve or further leverage these functions
- Oversee claim adjustment tools (Mass Claim Adjustment, Robot Process Automation, scripts) to enhance capabilities, reliability, and quality of reprocessing through various methods
- Oversee all claims regulatory reporting and prompt pay modeling
- Responsible for all member and provider communications including claim letters/remittance advice and explanation code governance
- Responsible for all post pay third party liability and direct billing
- Ensure operational effectiveness by leading strategic and business planning, including business, financial, and operational goals and objectives definition as well as feasibility studies to develop and implementation of departmental policies and procedures
- Ensure appropriate approvals, testing, and controls are in place and adhered to
- Develop and implement ticket controls and ensure appropriate proper communication and approvals are in place prior to system implementation
- Oversee and ensure that supporting business processes and documentation exists as a basis for system logic
- Drive Best in Class technical claim handling within the Claim Adjustment process, development, techniques, and methods for claims payment
- Lead initiatives with cross functional teams such as working with IT and others to automate claims functions and improve front end processes, implement new business including the design, testing and delivery of supporting processes to the business
- Recognize and proactively manage scope and expected benefits across claims strategic initiatives and process improvements and is a key contributor to the claims technical advancements
- Develop metrics and leading indicators to measure technical results and create/execute action plans as needed with other Operational Leaders
- Ensure quantitative and qualitative measures are used to meet performance objectives
- Implement opportunities for process improvement that impact operations, performance and quality
- Track issues and status to ensure proper follow-up and coordination
- Maintain project plans for all projects in which Process Development team is involved and ensure proper completion of those plans and escalation where timeframes will be changed
- Participate in strategic planning and implement action plans
- Review bulletins, newsletters, periodicals and attend workshops to stay abreast of current issues and trends, changes in laws and regulations governing claim reimbursement methodology, Business Process Automation (BPA), Robotic Process Automation (RPA), Facets User workshops, and any other industry events of value
- Oversight of documenting process development and improvements, testing, and promotion of changes following established departmental change management processes
- Development and maintenance of departmental change management process
- Perform any other job duties as requested
Education and Experience:
- Associate’s degree or equivalent years of relevant work experience is required
- Bachelor’s degree in business administration, healthcare or related field or equivalent years of relevant work experience is preferred
- Minimum of five (5) years of healthcare claims or operations experience is required
- Minimum of three (3) years of previous leadership experience is required
Competencies, Knowledge and Skills:
- Working knowledge of medical claims workflow and processing applications
- Knowledge of regulatory reporting and compliance requirements for Medicaid and Medicare
- Knowledge of managed care industry, claims trends and best practices
- Experience with automating processes through RPA tools and techniques
- Familiar with Agile methodology and application
- Medicaid/Medicare knowledge of managing inventory and assigning work
- Proficient in Microsoft Word and Excel
- Knowledge of medical coding (CPT, HCPCS, ICD) highly desired
- Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
- Ability to track/trend provider claim issues and develop solutions
- Excellent communication skills; both written and verbal
- Ability to work collaboratively with other management
- Time management skills; capable of multi-tasking and prioritizing work
- Effective decision making / problem solving skills
- Ability to effectively interact with senior management and executive staff
- Strong business and financial acumen preferred
Licensure and Certification:
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.