Job Number: 1122
Position Title: Manager, Claims
The Claims Manager is responsible for the direct supervision and coordination activities of its workers engaged in examining claims for payment by performing the following duties.
Essential duties and responsibilities include but are not limited to:
- Responsible for overseeing day-to-day workflows and activities of claims staff within the Claims department.
- Resolves issues and problems encountered in day-to-day Claims operations.
- Handles difficult claims and reviews high dollar claims for accuracy and ensure processes are in place to ensure appropriate and timely payment. Ensure effective system to address stop loss, cob and other higher level claims are in place.
- Ensure inventory and quality are maintained via reports and analyzing of data, including reporting weekly DROH and any issues
- Identify any root causes based upon analysis of data and report such issues to the appropriate unit for resolution.
- Oversee the process of claims customer service process and ensure issues are addressed timely and succinctly.
- Determines work procedures, prepares work schedules, and expedites workflow. Coordinates staffing of day-to-day activities as well as assigns and monitors work of staff in order to adhere to productivity and quality standards.
- Plays a key role in training, problem resolution, work floor optimization and process improvement. Identifies candidates for additional responsibility and development.
- Informs direct report and other necessary internal staff of claims status as necessary.
- Recognized by management and staff as an expert in issues related to claims processing, payment dispute resolution, cost containment, audit processes and contract interpretation. May be required to perform responsibilities, as workload and staffing require.
- Ensures compliance with policies, procedures and practices.
- Assists team in meeting or exceeding departmental performance standards.
- Subject matter expert to assist with regulatory audits, as required as well as prepare materials required for regulatory audit submission.
- Overall performance accountability (attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation). Maintains a positive and productive work environment.
- Ensures complete and sound claim settlements, legal reviews and investigations when necessary.
- Oversight of claims delegations functions to include, but is not limited to audits, training, review of policies and procedures.
Carry out supervisory responsibilities in accordance with organization policies and applicable laws. Responsibilities include interviewing, hiring and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience: Requires a bachelor's degree in a related area and/or at least 10 years of experience in the field. Familiar with a variety of the field's concepts, practices, and procedures. Relies on experience and judgment to plan and accomplish goals. Manages the claims staff and typically reports to top management.
- Certificates, Licenses, Registrations: None required.
- EZCap system knowledge is preferred.
- Understanding and hands-on expertise with Medicare Advantage/HMO claims processes
Skills and Abilities
- Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
- Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Knowledge of computer programs and applications required.
- Other Skills and Abilities:
- Knowledge of medical terminology
- Detail oriented.
- Follow instructions accurately.
- Must know computerized claims processing systems.
- Data entry and 10-key skills by touch and sight.
- Knowledge of MS Office – Outlook, Word, and Excel.
- Knowledge of claims coding, CPT, RVS, ICD-9, HCPCS or other coding.
- Knowledge of State and Federal Regulatory claims requirements.
- Comprehensive knowledge of medical terminology.
- Excellent verbal and written skills.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms.
- The employee is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 25 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
- Some travel maybe required.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
Location City: Tampa
Location State: Florida
Community / Marketing Title: Claims Manager
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact firstname.lastname@example.org.