SCOPE OF ROLE

The Manager, Claims position will work jointly with leadership to develop, grow and manage the commercial claims department, ensuring that internal and external service level agreements are met. In addition, this position has accountability for ensuring that teams comply with all state and federal regulations including those from CMS and multiple state divisions of insurance.

ROLE RESPONSIBILITIES

The Manager, Claims job description is intended to point out major responsibilities within the role, but it is not limited to these functions. The Manager, Claims will oversee the daily operation of our Third-Party Administrator, including, but not limited to:

• Manage Claims Backlog within state specific Clean Claims turnaround times
• Monitor departmental performance metrics to ensure key performance measures and Service Level Agreements are achieved
• Conduct Pre-Payment Audit of all high dollar claims
• Research and respond to Claim Escalations from Provider Relations, Member Services and Clinical Operations
• Facilitate the research and resolution of claims issues arising from Appeals and Grievances
• Collaborate with Third-Party Administrator to configure plan benefits and facilitate claim testing
• Review and correct claims data errors arising from Edge Server rejections
• Other duties and responsibilities as assigned

SUPERVISORY RESPONSIBILITIES

This position has supervisory responsibilities for the claims operations staff.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• High School diploma or GED required; Bachelor’s Degree preferred
• Three (3)+ years’ experience in a supervisory capacity
• Five (5)+ years’ claims processing experience

PROFESSIONAL COMPETENCIES

• Comprehensive understanding of all aspects of claims processing
• Must have strong communication skills (verbal and written)
• Must be highly organized and be able to prioritize work to meet deadlines
• Display strong strategic behaviors such as initiative, problem solving, critical thinking, judgment, innovation and independence
• Ability to influence and collaborate with business partners throughout the organization.

WORK ENVIRONMENT

The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.