Claims Manager

Solis Health Plans

About The Position

The Claims Manager is responsible for the oversight of Solis Health Plans end-to-end claims processing operations. This role ensures accurate, timely, and compliant adjudication of Medicare Advantage claims in accordance with CMS regulations, state requirements, and organizational policies. The Claims Manager leads a team of claims analysts and processors while driving operational efficiency, quality improvement, and regulatory compliance.

Requirements

Bachelor’s Degree in Healthcare Administration, Business, or related field (or equivalent experience).
2 years’ experience with complex claims processing and/or auditing within the health insurance industry or medical healthcare delivery system
2 years’ experience with Medicare Advantage (Part C) claims required.
2 years’ experience in a managed healthcare environment related to claim processing/auditing, including Medicare plans
2 years’ experience with CMS requirements, and other complex claim processing rules and regulations
2 years’ experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes
Recent Institutional and Professional claim payment experience.

Responsibilities

Oversee daily claims processing activities, including intake, adjudication, adjustments, and appeals.
Ensure claims are processed accurately and within established turnaround times (TATs).
Monitor workflow and staffing to meet productivity and service level goals.
Establish best practice claims payment methodology based on current CMS claims payment regulations
Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internal system and beneficiary impact
Coordinate with Network Services and Provider Relations teams to ensure proper reimbursements
Provide exceptional service to providers, internal and external customers in accordance with Company values
Forecast all staffing requirements, schedule workforce accordingly.
Complete regular review of internal reporting (ex., high dollar claims)
Ensure compliance with Centers for Medicare & Medicaid Services (CMS) guidelines, Florida Agency for Health Care Administration (AHCA) requirements, and HIPAA regulations.
Maintain up-to-date knowledge of Medicare Advantage rules, including claims processing edits and reimbursement methodologies.
Participating in and supporting ad-hoc audits as required.
Collaborate with Utilization Management Team as well as Grievance and Appeals Team when necessary
Complete all assigned claim projects.
Work in collaboration with Payment Integrity Manager to implement and manage quality assurance programs to ensure high accuracy rates.
Manages multiple functions requiring unique sets of knowledge or Fiscal accountability over and above routine people/equipment costs.
Ensure effective communication with delegated vendors when applicable.
Develop and maintain reports on claims inventory, aging, accuracy, and productivity.
Analyze trends and provide actionable insights to senior leadership.
Effective supervision, mentor, and develop claims staff, including hiring, training, performance management, scheduling, work allocation and problem resolution.
Responsible for performance evaluation of team members and making recommendations for appropriate action, as well as motivating team members to achieve peak performance and productivity.
Continuing education and development of team members to adapt to sales deviations and business restructuring.
Maintain a reliable staffing model to ensure appropriate staffing levels.
Develop corrective action plans and track performance improvements as a result of quality assurance audits.
Identify inefficiencies and implement process improvements and automation where applicable to increase claims auto adjudication.