The Claims Manager is responsible for the daily operation of the front-end claims' examiners. This position ensures regulatory compliance in the processing of all inbound claims that are within the Centers for Medicare & Medicaid Services (CMS) regulations as well as Clever Care Health Plan policies and procedures as they apply to claims processing and payment. The Manager will maintain claims policies and procedures, job aids, examiner performance scorecards and claims desktops for a large enterprise claims operation. The Manager is responsible for guiding and directing staff performance, productivity and efficiencies. The Claims Manager will work closely with the enrollment, provider data management and utilization management teams for EzCap system adjudication workflow updates.

Functions & Job Responsibilities

• Manages the claims department to meet operational, financial, compliance and service requirements.
• Hires, trains and supervises on-shore and off-shore staff; conducts performance reviews and completes corrective actions as applicable.
• Monitors staff's performance and ensures adherence to policy/procedures and the highest level of customer service.
• Coordinates daily claims operations including; monitoring inventory priorities, adherence to Medicare processing guidelines, EzCap workflow queues, and key performance indicators (KPIs) and metrics, compliance of regulatory and quality standards including but not limited to Centers for Medicare and Medicaid Services (CMS) requirements.
• Conducts presentations or designates staff to present at provider relation workshops related to claims submission, new claims programs being implemented and current billing guidelines.
• Performs monthly audits on claims for compliance with CMS guidelines, reports results to Senior VP of Operations on a monthly basis.
• Directs audit preparations, reviews universes for possible risk areas or trends, documentation gathering, remediation action plans, and presentations.
• Responsible in submitting reports such as MTR, ODAG, financial reports, board of director claims report, and other assigned tasks.
• Prepare, review documents for internal claims audit. Work with the Compliance Department on CMS audits.
• Develops, implements, updates, and reviews remediates and reports findings; forwards impact and remediation plans to upper management for processing desktops, job aids and data base reporting tools for new Clever Care programs and EzCap claims adjudication updates.
• Ensures processing turn-around times for claims processing are met and processed as follows; Medicare claim payments are completed as follows; 95% in 30 days (clean claims) and 60 days (unclean).
• Serves as the subject matter expert, represents claims at interdepartmental meetings and provides back up support to claim processing as needed. Schedules regular monthly unit meetings to go over any changes to programs or training issues; holds one-on-one meetings with staff to address their monthly progress on success factors (production, quality, etc.).
• Communicates job expectations and improvements as needed.
• Establish new process, review existing process to boost efficiency, increase productivity and eliminate redundancies.
• Analyzes production goals, trends and recommends work performance standards modification as needed.
• Completes other projects and duties as assigned.

#LI-Hybrid

Qualifications

Education:

• High School diploma or equivalent required. Associate degree or an equivalent combination of education and claims processing experience preferred.

Experience:

• 3 years of experience in a managed care claims processing environment required.
• 4 years of Senior Examiner, Lead or Supervisory experience in directing the work of others (i.e. training, responding to questions, etc.) required.
• 2 year of experience in HIPAA requirements required. Knowledge of: CMS and/or DMHC claims processing guidelines or regulations.
• Terminology, CPT, revenue codes, ICD10, HCPCS codes as it relates to claims processing adjudication. Core claims processing systems and healthcare authorization systems.

Skills:

• Establish and maintain interpersonal relationships internally/externally and utilize skills by; coaching and motivating staff, handling conflict resolution, implementing project or new programs/initiatives and collaborating with other departmental subject matter experts.
• Perform in a fast-paced environment and work under pressure.
• Communicate clearly and concisely, both verbally and in writing to individuals of diverse backgrounds.
• Organize, plan and prioritize work activities, possess analytical and problem-solving skills.
• Troubleshoot claims adjudication problem areas.
• Encourage and utilize suggestions and new ideas.
• Comprehend and interpret provider contracts and Divisional Financial of Responsibility (DOFR).
• Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems (e.g. EZCAP Claims Processing System and Authorization system) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.