Manager, Coding (Claims Operations)

Health insurance that's with you, every step of the way.•Minnetonka, MN

14h•Hybrid

About The Position

Medica is a nonprofit health plan serving more than a million members across Minnesota, Nebraska, Wisconsin, Missouri, and beyond. The Manager, Coding oversees the Payment Analytics and Reimbursement Policy departments to support 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. This is a working manager role that oversees communication of team results and works collaboratively to improve pre-payment solutions, recoveries, claims payment accuracy, claims adjustment volumes, provider service, financial liability, and provider billing patterns. The manager may perform, review, or summarize audits and trains incoming staff on audit practices and procedures. The position is an office role requiring onsite work an average of three days per week, with candidates based near 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.

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 experience developing metrics, performance measures, and data-driven operational strategies.
Proven 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 implementing sustainable corrective actions.
Experience influencing cross-functional stakeholders and leading teams to achieve operational and financial objectives.

Responsibilities

Develop forecasts of 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 effective working relationships with Medica’s claims 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 executive reporting packages and report financial impacts to management.
Understand Medica’s contracting strategy and its relationship to provider reimbursement and system capabilities.
Report overpayments or suspected fraudulent behavior to the Special Investigations Unit.
Maintain reporting structures and consistency for internal and external customers.
Improve processes through automation and other efficiencies.
Review and analyze team findings monthly, quarterly, and annually to identify trends and areas for focus and improvement.
Ensure processes are auditable and can be reperformed using 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 and participate in projects assigned by the director.
Educate and advise customers about processes, content, and trends.
Promote integration and collaboration with pharmacy operations, payment integrity and 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 and perform general management duties, including coaching, meetings, issue escalation and resolution, and performance measurement.
Recruit, select, retain, and support performance improvement for department staff in coordination with the department director.
Conduct annual performance reviews, maintain staff morale, promote teamwork, and recognize staff through reward and recognition programs.
Coach and support staff growth and development through timely, consistent feedback and technical assistance; ensure staff receive needed training and growth opportunities.
Collaborate with the team to create and maintain department policies, procedures, and swim lanes.
Establish processes 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.