Claims Manager

The Claims Manager is responsible for the daily management of the Medical Claims Processing team members. This position demonstrates high levels of expertise in the department’s operations; provides training and staff development; performs administrative duties and support to deliver high levels of service, quality and production. This position should have a comprehensive understanding of the Plan Documents/Guidelines under their scope of responsibility.

Essential Job Duties:

• Maintain HIPAA/PII guidelines to ensure the confidentiality of all calls and documents 

• Administrative 

     o Serve as a liaison between departments, vendors and clients to ensure collaborative progress 

            ? Exhibit strong working knowledge of customer business operations

     o Demonstrate strategic business acumen in decisions affecting bottom line focus

     o Generate and deliver accurate and timely reports

     o Assist with troubleshooting for technical issues

• Customer Service

     o Serve as a role model in demonstrating core values of customer service 

     o Encourage continuous learning, personal development and accountability through team members

     o Provide timely and thorough responses to internal and external customers

           ? Respond to member and group correspondences regarding plan/guideline or claim questions within 24 hours

     o Escalate difficult issues to the appropriate channels

     o Assist in the processing and resolution of escalated issues

• Quality Assurance

     o Ensure team compliance with service standards

     o Follow trends within assigned scope and alert appropriate parties of any trends that fall outside quality parameters

     o Develop and execute plans to meet established goals 

     o Provide continuous feedback to strengthen and optimize quality performance

     o Work cross-departmentally to improve or streamline procedures

     o Maintain up to date knowledge on industry trends and look for new data sources

     o Develop new and improve current internal processes to improve overall quality 

• Special projects as assigned

Management Responsibilities:

• Conduct regular performance evaluations of employees and provide ongoing feedback and coaching as necessary

• Address and counsel employees on behavioral or performance problems and implement corrective action as necessary

• Explain and administer company policies required for team members to perform duties successfully 

• Distribute and monitor departmental workloads to ensure adequate coverage while meeting quality and service levels

• Oversee new and ongoing training and update training manuals 

• Coordinate and actively participate in departmental meetings

Skills/Abilities:

• Excellent verbal and written communication skills with high attention to detail

• Excellent customer service skills 

• Strong analytical and problem-solving skills

• Confident decision-making abilities

• Demonstrated ability to work independently, prioritize workloads and manage priorities to meet deadlines

Education/Experience:

· College degree or equivalent required

· Degree in Medical Billing and Coding or related field preferred

· Knowledge of medical terminology preferred

· 7 -10 years Claims Examiner experience or equivalent required

· 4 -7 years management experience required

Physical Requirements:

· Indoor office environment with moderate noise

· Intermittent physical effort may include lifting as much as 25 lbs., walking, stopping, kneeling, crouching or crawling may be required

· Frequent sitting, use of a keyboard, reaching with hands and arms, talking and hearing approximately 70% of the time; 30% or less time is spent standing

· Normal vision abilities required including close vision and ability to adjust focus