Delegation Oversight Manager, Claims

Job Number: 1194

Workplace Type:

Position Title: Delegation Oversight Manager

External Description:

Claims Delegation Oversight Manager

The Claims Delegation Oversight Manager is responsible for the direct oversight and auditing of Alignment Health Plan’s delegated entities as it relates to claims processing.

General Duties/Responsibilities:

(May include but are not limited to)

• Responsible for oversight and auditing for downstream entities delegated for claims processing.
• Conduct pre-delegation evaluations for potential delegated entities (IPAs) which includes:
• • Site visit
  • Written review
  • Staffing capabilities
  • Performance records
  • Exchange of documents or through pre-meetings
• Audits delegated entities to ensure performance maintenance through the following:
• • Review contractually established performance metrics monthly
  • Use a range of data sources to evaluate adherence to compliance
  • Immediately and clearly share new state guidance with delegates
  • Set rules for sub-delegation
• Performs performance correction of delegated entities through the following:
• • Communicate overall needs to delegates—define big picture success for them
  • Have a corrective action approach where an oversight for those delegates who fail to meet expectations which includes:
  • • Calls
    • Letters
    • Corrective action plans
    • Be prepared to terminate provider for failure to meet performance levels
• Performs annual claims audits/evaluations via desk and onsite audits

• Evaluate adherence to plan oversight requirements

• Obtains required claims compliance reporting, which includes but not limited to:  monthly timeliness reports, Part C reporting, Provider Dispute Resolution and ODAG.
• Conducts, at minimum, annual on sight claims audits/re-audits with delegated entities to ensure adherence to CMS regulations related to claims processing and
• Issue and monitor corrective action plans for those delegated entities not meeting claims processing compliance standards.
• Develop delegation oversight and audit policies, protocols/procedures and tools.
• Streamline oversight activities to ensure as much automation and efficiencies as possible.
• Conduct monthly oversight meetings with Executive Leadership to provide updates on delegated claims activities.
• Works in conjunction with internal Compliance and Delegation Oversight and Monitoring Manager.
• Makes recommendations on those delegated entities that are consistently not in compliance with claims processing standards.
• Other duties as assigned.

 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: 

1. 1. Requires a bachelor's degree in a related area and/or at least 5 years of experience in the field. Familiar with a variety of the field's concepts, practices, and procedures.
   2. Relies on experience and judgment to plan and accomplish goals. Manages staff and typically reports to top management.
   3. At least 2 years of management experience
   4. Prior Medicare Managed Care claims processing experience related to delegation oversight and auditing.
   5. Demonstrable detailed knowledge/experience with CMS claims compliance reporting – Part C, ODAG, Monthly Timeliness, etc.
   6. Certificates, Licenses, Registrations:  None required.

Skills and Abilities

1. Possesses and demonstrates a strong willingness/openness to change and actively make improvements towards efficiencies and automation.
2. Possesses and demonstrates a strong working knowledge in claims processing for Medicare Advantage members based on CMS regulations and guidelines.
3. Possess strong written and verbal skills.
4. Ability to present to Executive Leadership audience.
5. Ability to be proactive and solution oriented.
6. Possesses strong follow up and follow up abilities.
7. Possesses abilities to scope and identify potential issues and escalate accordingly and proactively.
8. Possesses and maintains strong working knowledge of regulatory and compliance claims reporting.
9. Possesses prior experience with system testing and leading User Acceptance Testing sessions.
10. Possesses strong ability to evaluate data for accuracy and integrity in order to report on any issues and trends.
11. 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.
12. 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.
13. 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.
14. Computer Skills:  Knowledge of computer programs and applications required.  Highly experienced skillset with using MS Office products such as MS Excel, Access, Word, etc.

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. 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.

 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: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Delegation Oversight Manager, Claims

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].