Job Number: 1122

Workplace Type:

Position Title: Manager, Claims

External Description:

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.

Summary 

Essential duties and responsibilities include but are not limited to:

1. Responsible for overseeing day-to-day workflows and activities of claims staff within the Claims department. 
2. Resolves issues and problems encountered in day-to-day Claims operations.
3. 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.
4. Ensure inventory and quality are maintained via reports and analyzing of data, including reporting weekly DROH and any issues
5. Identify any root causes based upon analysis of data and report such issues to the appropriate unit for resolution.
6. Oversee the process of claims customer service process and ensure issues are addressed timely and succinctly.
7. 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.
8. Plays a key role in training, problem resolution, work floor optimization and process improvement.   Identifies candidates for additional responsibility and development.
9. Informs direct report and other necessary internal staff of claims status as necessary.
10. 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.
11. Ensures compliance with policies, procedures and practices.
12. Assists team in meeting or exceeding departmental performance standards.
13. Subject matter expert to assist with regulatory audits, as required as well as prepare materials required for regulatory audit submission.
14. Overall performance accountability (attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation).  Maintains a positive and productive work environment.
15. Ensures complete and sound claim settlements, legal reviews and investigations when necessary.
16. Oversight of claims delegations functions to include, but is not limited to audits, training, review of policies and procedures. 

Supervisory Responsibilities 

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. 

Qualifications 

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.

1. Certificates, Licenses, Registrations:  None required.
2. EZCap system knowledge is preferred.
3. Understanding and hands-on expertise with Medicare Advantage/HMO claims processes

Skills and Abilities 

1. 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.
2. 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.
3. 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.
4. Computer Skills:  Knowledge of computer programs and applications required.

1. Other Skills and Abilities:

1. Knowledge of medical terminology
2. Detail oriented.
3. Follow instructions accurately.
4. Must know computerized claims processing systems.
5. Data entry and 10-key skills by touch and sight.
6. Knowledge of MS Office – Outlook, Word, and Excel.
7. Knowledge of claims coding, CPT, RVS, ICD-9, HCPCS or other coding.
8. Knowledge of State and Federal Regulatory claims requirements.
9. Comprehensive knowledge of medical terminology.
10. Excellent verbal and written skills. 

Physical Demands 

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.

1. 1. 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.
   2. The employee is frequently required to reach with hands and arms.
   3. The employee is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl.
   4. The employee must occasionally lift and/or move up to 25 pounds.
   5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
   6. Some travel maybe required.

Working Environment 

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. 

1. The noise level in the work environment is usually moderate.

City: Tampa

State: Florida

Location City: Tampa

Location State: Florida

Community / Marketing Title: Claims Manager

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].