Sr. Manager - Claims

Astrana Health, Inc.•Monterey Park, CA

13h•Hybrid

About The Position

We are currently seeking a highly motivated Claims Manager. This role will report to the AVP - Claims Operations and enable us to continue to scale in the healthcare industry.

Requirements

Minimum of a Bachelor's degree (B. A.) from a four-year college or university; or four (4) years current Management or equivalent experience with an MSO or IPA Management
Full knowledge of DMHC, DHS and CMS Regulations and Guidelines, ICD-10, CPT, RV/RBRVS codes
Experience with contract law and Division Responsibility matrix interpretation
Comprehensive knowledge in the AB1455 regulations

Nice To Haves

EZCAP experience is a huge plus

Responsibilities

Responsible for quality and performance metrics of processing teams that are assigned
Collaborate with other Teams as directed that are newly contracted and need to be implemented
Manage claims inventory to minimize claims turnaround times and ensure contractual SLAs are met
Drive continuous improvement efforts to improve claims quality and efficiency
Resolve processing/system issues within assigned department and across all IPAs
Prioritize work volumes on a daily basis
Oversee status of production in assigned department to ensure production and quality goals are being met
Analyze impact of new implementations on assigned department and reallocate staff duties as necessary
Onboard a large IPA that has global risk to ensure a successful implementation addressing and working with run out for the group, ensure accuracy, timeliness and meeting all regulatory requirements for a smooth transition
Training off-shore staff to take on a large IPA that is completely new to the organization and ensuring that there are no issues of non-compliance inaccuracies or problems that are brought to the attention of Astrana-This is a huge lift considering the volume of membership, claims run-out responsibility and ensuring there is no lapse in their claims adjudications and payment processes moving forward
Utilize claims management systems to provide reports and analysis to management on a regular basis
Develop team members to ensure accountability for achievement of departmental goals and objectives
Update and facilitate implementation of process and workflow modifications to improve operational efficiency
Educate and train claims employees on the overall claims process and best practices for successful outcomes
Address claim inquiries and claim payments by sensitive providers and members
JOC meetings-attendance and corrective action response when required
System updates maintaining the integrity of the Claims Payment Database; working inter-departmentally with other managers
Off-site Seminars IE: E-Z Cap and HMO Regulatory training.
High level grievances or claim reconsideration request for reimbursable claim reviews as needed
Evaluate trends in compliance findings to determine root cause and work with Director on remediations such as IDNs, EOBs, and all other findings that need to be addressed with the claims teams or Senior Leadership
Address non-compliance to Departmental standards with the examiners to include disciplinary actions, PIPs, Training plans and coaching
Job Descriptions- format a standardized Claim Department Organizational Chart outlining performance responsibilities and requirements for each position
Performance evaluation- monitors track and documents the annual performance evaluation of each Claim Department staff
Recruit monitor, and document the attendance, production and work quality of Claim Department staff to include employee counseling and/or termination in accordance with HRIS Guidelines
Staff analysis and growth potential
Maintain open and effective channels of communication between staff and management
Represent DMHC Regulatory and CMS Claims Payment Compliance issues at Management Meetings and with the Executive Board
Using all tools available ( IE: Industry Communications, Seminars, Internet, Professional Networking) to maintain the most current levels of understanding of trends, occurrences, ideology and law that will affect the operation, compliance and stability of the Claims Department and of Astrana
Communicate this information timely and effectively to both Claims Department Staff and to Management
Maintains the strictest confidentially at all times
Responsible for other miscellaneous assignments as requested by Management