Manager, Coding (Claims Operations)

Medica•St. Louis, MO

1d•$78,700 - $134,900•Hybrid

About The Position

The Manager, Coding is responsible for Medica’s Payment Analytics and Reimbursement Policy departments to help ensure appropriate provider claim payment. The role reports results and month-over-month trends to senior leadership, reverse engineers vendor savings, identifies medical cost leakage, and shares and absorbs insights that may lead to future findings. The manager oversees communication of team results and works collaboratively to improve pre-payment solutions, recoveries, claims payment accuracy, claims adjustment volume, provider service, financial liability, and provider billing patterns. This is a working manager role that may involve performing, reviewing, or summarizing audits and training incoming staff on audit practices and procedures. Other duties may be assigned. The position is an office role requiring onsite work an average of three days per week. Candidates may be located near Medica’s offices in Minnetonka, Minnesota; Madison, Wisconsin; St. Louis, Missouri; or Omaha, Nebraska. The full salary grade is $78,700–$134,900, with a typical hiring range of $78,700–$118,020. The role may also be eligible for incentive compensation. Medica does not offer work visa sponsorship; applicants must be legally authorized to work in the United States at the time of application.

Requirements

Bachelor’s degree or equivalent experience in a related field.
At least 7 years of progressive work experience in claims and coding beyond the degree.
At least 5 years of people leadership experience in healthcare operations.

Nice To Haves

Strategic thinking and experience developing metrics, performance measures, and data-driven operational strategies.
A track record of continuous improvement and process optimization in a healthcare or operational environment.
Strong analytical skills, including tracking, trending, and interpreting data to identify opportunities and inform business decisions.
Expertise in issue resolution and root cause analysis, including implementation of sustainable corrective actions.
Experience influencing cross-functional stakeholders and leading teams to achieve operational and financial objectives.

Responsibilities

Develop forecasts for potential and error savings goals based on claims data analysis.
Oversee analysts’ day-to-day processes for monthly savings efforts.
Recover overpayments identified through retrospective data analytics.
Identify root causes of errors, influence stakeholders, sponsor process improvements, and enhance claims editing solutions.
Maintain a working relationship with Medica’s claim processing vendor to improve claim policy management, processing accuracy, and adjustment reduction.
Maintain current knowledge of corporate policies, regulatory codes, legislative directives, and other guidelines.
Set priorities for staff following up on payment integrity leads from vendors.
Develop an executive reporting package.
Understand Medica’s contracting strategy and its relationship to provider reimbursement and system capabilities.
Report overpayments or suspected fraud to the Special Investigations Unit (SIU).
Monitor, manage, and report financial impact to management.
Maintain consistent reporting for internal and external customers.
Improve processes through automation or other efficiencies.
Review and analyze team findings monthly, quarterly, and annually to identify trends and opportunities for focus and improvement.
Ensure processes are auditable and can be reperformed with a paper or electronic trail.
Serve as a subject matter expert for internal and external customers on waste, errors, and Payment Analytics and Reimbursement Policy processes.
Manage or participate in projects assigned by the director.
Educate and advise customers about processes, content, and trends.
Promote integration and collaboration with Medica stakeholders, including pharmacy operations, payment intent/cost containment, network management, SIU, claims operations, operations audit, and internal audit.
Develop, monitor, and report goals and metrics for analytic identification and reimbursement policy effectiveness.
Achieve department production goals.
Perform general management duties, including coaching, team and one-on-one meetings, issue identification, escalation and resolution, and performance measurement.
Coordinate recruitment, selection, retention, and performance improvement with the department director.
Conduct annual performance reviews.
Support staff morale and teamwork, and provide recognition through reward and recognition programs.
Coach and facilitate individual growth and development through specific, timely, consistent feedback.
Provide timely technical support, guide staff to appropriate resources, and ensure necessary role training and growth opportunities.
Collaborate with the team to create and maintain department policies, procedures, and swim lanes.
Ensure processes are established among Medica, post-pay compliance vendors, and claims processing vendors.
Perform, review, or summarize audits as needed and train incoming staff on audit practices and procedures.
Perform other duties as assigned.