• Claims Manager

    Job Locations US-CA-Fairfield
    Job ID
    2018-1288
    Category
    Claims
  • Overview

    To manage the Claims Supervisors. Provides overall project support for all functions for the assigned area. Works across functional areas within the Claims Department on projects assigned. Ensures delivery of highest level of customer service to the community and its medical providers.

    Responsibilities

    • Manages the Claims Supervisors and claims functions in each respective area.
    • Ensures units are compliant with claims quality indicators and inventories. Identifies deficiencies; develops and implements corrective action plans and trains staff as needed.
    • Interviews and participates in the selection of qualified candidates for the Claims Supervisor, Specialist, Examining, Customer Service, Analyst positions. Evaluates performance and provides developmental opportunities for Claims Supervisors and line staff. Provides training for new Supervisors as needed. Counsels performance problems or issues when needed. Reviews and signs time cards.
    • Reviews department policies and procedures, recommends changes for more efficient operations, draft new policies and procedures for Director’s review, communicates changes and updates to staff when appropriate.
    • Works across units to develop training needs and materials.
    • Reviews and signs claims adjustments and high dollar claims within established guidelines.
    • Participates in PHC audits and in audits of delegated entities.
    • Participates in special projects, activities, and assignments as needed.
    • Participates in the monthly interdepartmental claims configuration meeting.
    • Provides back-up for the other Manager in the Claims Department.
    • Other duties as assigned.

    Qualifications

    Education and Experience

    Bachelor’s degree in related field preferred; minimum two (2) years of supervisor experience in a claims environment; or equivalent combination of education and experience.

     

     

    Special Skills, Licenses and Certifications

    Strong written/oral communication and organization skills. Knowledge of AMISYS or similar system. Understanding of claims processing, related subsystem interfaces, and how changes impact all AMISYS subsystems. Thorough knowledge of CPT, HCPC procedure coding, and ICD-9 diagnostic coding. Knowledge of medical terminology. Expertise in automated claims procedures and related problem resolution.

     

     

    Performance Based Competencies

    Must be able to work in a fast paced environment and maintain courtesy and composure when dealing with internal or external customers.

     

     

    Work Environment And Physical Demands

    Ability to use a computer keyboard. More than 70% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 10 lbs.

     

     

     

     

     

    All HealthPlan employees are expected to:

     

    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

     

    IMPORTANT DISCLAIMER NOTICE

     

    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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