Manager of Claims Data Management

HCA Healthcare•Nashville, TN

53d

About The Position

The Manager of Data Management is responsible for overseeing the daily operations of the Data management team. The Data Management team is responsible for ensuring that claims processing platform is optimally and accurately configured to meet the organization's strategic business operations. The Encounter team is responsible for designing, developing, and maintaining organizational programs that support contractual requirements of payer contracts, including but not limited to encounter programs. Additionally, this role will be responsible for leading and mentoring a team of technical professionals.

Requirements

Extremely strong verbal and written communication skills targeted at both high-level external stakeholders as well as internal peers and executives.
Strong management and interpersonal skills to facilitate team towards achievement of stated functional goals as well as to help develop internal skill sets and performance.
Advanced knowledge of healthcare, managed care, contract related activities including negotiations, legal, regulatory, operational, financial and relationship management.
Bachelor's Degree or equivalent combination of education and 5+ years of work experience.
5+ years of experience in managed healthcare, analysis, and problem solving required.
5+ years of experience managing a team supporting managed healthcare systems/processes required.

Nice To Haves

7+ years professional managed healthcare administration experience in IPA with 5+ years management experience preferred

Responsibilities

Ensure claims processing platform is optimally and accurately configured and maintained to meet the organization's strategic business operational needs specific to vendor contracts, fee schedules, benefits/DOFR, and provider/vendor/place of service data. Responsible for developing and updating policies and procedures which support application system setup functions and work/audit processes within claims processing platform.
Provider data management: Oversees the configuration of provider-specific data, including fee schedules, reimbursement methodologies, network assignments, and demographic information.
Benefits configuration: Translates complex benefit plan documents (like Summary Plan Descriptions) into system rules, logic, and cost-sharing structures such as co-pays, deductibles, and out-of-pocket maximums
Contract and pricing implementation: Accurately configures and tests new and updated provider contracts and pricing models to ensure correct claims payments according to negotiated terms.
Coding and logic setup: Ensures the system correctly processes claims based on standard coding systems, including CPT, ICD-10, and HCPCS
Represents the Data Management team to executive management and follows up with internal customers to ensure all business objective expectations are met. Works to established service levels per business requirements and acts as the primary point of escalation for the Data Management team.
Manage yearly CMS rate change implementation and validation.
Identifies opportunities to enhance operational efficiency, accuracy, and auto-adjudication rates within the claims system through workflow and process improvements.
Establishes quality control metrics and tracking mechanisms for configurations. Manages testing and validation of all system changes before implementation.
Works closely with other departments, including Claims Operations, IT, Provider Contracting, and Compliance, to align on system setup and resolve issues.
Supports system migrations, client implementations, and other special projects that impact claims configuration.
Acts as an escalation point for complex configuration and claims processing issues, performing root cause analysis and implementing corrective actions.
Stays current with federal and state healthcare regulations (e.g., ACA, HIPAA) and ensures all system configurations comply with legal standards
Coordinates responses to internal and external audits, implementing new processes to address any findings and ensure compliance.
Monitors configuration performance and generates regular reports for management on quality metrics, system error rates, and team productivity.
Create and lead a scalable program that includes encounter data management, submissions, reject remediation, and client/internal reporting as well as coordination and reconciliation with state regulatory bodies.
Leads analyses independently and coordinates with the Finance Division to review financial performance based on encounter submissions. Perform other duties as assigned.

Benefits

Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
Free counseling services and resources for emotional, physical and financial wellbeing
401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
Employee Stock Purchase Plan with 10% off HCA Healthcare stock
Family support through fertility and family building benefits with Progyny and adoption assistance.
Referral services for child, elder and pet care, home and auto repair, event planning and more
Consumer discounts through Abenity and Consumer Discounts
Retirement readiness, rollover assistance services and preferred banking partnerships
Education assistance (tuition, student loan, certification support, dependent scholarships)
Colleague recognition program
Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.