Claims Manager- Bakersfield 1.1

Universal Healthcare MSO•Bakersfield, CA

15d•Onsite

About The Position

The Claims Manager will provide leadership within the claims department, focusing on enhancing productivity, maintaining high-quality standards, and ensuring accuracy in claims processing. This role involves directing day-to-day workflows, managing personnel, and monitoring production and quality standards. The Claims Manager will actively develop and maintain departmental efficiencies for direct reports, utilizing performance management strategies to sustain productivity. Collaborating closely with the Enrollment team, the Claims Manager ensures accurate adjudication of claims through meticulous system setup. Additionally, the Claims Manager plays a crucial role in communicating essential information related to technology troubleshooting, workflow concerns, and new implementations vital to the department's success to the Chief Operations Officer.

Requirements

Minimum of 5 years of experience handling all managed care product types in an IPA/group setting.
Minimum of 5 years of supervisory or management experience preferred.
Strong knowledge of professional and institutional claim processing procedures, including COB/TPL/WC. Must be a self-starter who is detailed and result oriented.
Strong knowledge of fee schedule and pricing methodologies for outpatient/inpatient institutional, ancillary, and professional claims.

Responsibilities

Must effectively manage the claims inventory and provide timely and accurate claims and encounter processing.
Overall accountability for ensuring the design and development of claims workflow, policies and procedures as well as make appropriate recommendations that will positively impact operational effectiveness.
Responsible for meeting and exceeding operational productivity standards and for ensuring that claims are processed within the timeliness guidelines, while ensuring accuracy and quality
Assure compliance with all contractual and regulatory agencies for all product lines and governing bodies.
Ensure proper utilization of human and system resources to achieve stated performance objectives for productivity, quality, data integrity and financial controls within budgetary constraints.
Participates in the review and revisions of productivity and quality standards, as needed.
Aids senior management in the implementation of new business objectives, EZ-Cap upgrades, and other technical and vendor implementations related to claim processing.
Monitors inventory or other reports daily to ensure adequate resources are applied to maintain departmental goals of timeliness and quality.
Determine areas within the department requiring concentrated training efforts and plan appropriate actions to address training needs.
Participate in organizational planning, including development and revision of action plans and outcomes evaluation as appropriate.
Oversee department activities to ensure health plan and regulatory compliance is maintained.
Develop and modify policies and procedures, as needed.
Responsible for a full range of activities which ensure the operational effectiveness and excellence of the claims department.
Participate with other departments and cross-functional work groups on issues related to departmental and organizational efficiencies.
Provide support to staff in efforts to maximize efficiencies of staff.
Assist in the development of automated solutions to prevent adjudication errors.
Develop departmental and individual goals.
Assure staff has the information and tolls necessary to perform their functions.
Provide Leadership with feedback regarding departmental functions.
Interact with internal departments to correct procedural and system problems.
Monitor productivity and accuracy of unit staff as they adjudicate, adjust, perform analysis, and research claim projects.
Actively participates in the recruiting, hiring and performance management of claims staff.
Other related duties as assigned.