Our Brentwood, TN healthcare client is looking for a Manager of Claims to join their fast-paced team on a direct hire basis.
Summary: Leads, motivates and manages large, first dollar claims processing and adjudication department. Assures accurate and timely processing of claims, within company guidelines, for all Medicare Advantage products.
Duties and Responsibilities:
Oversee development, documentation and implementation of strategies, policies and procedures for prompt and accurate claims payment. Monitor the process/workflow of Medicare Advantage claims processing.
Review Federal regulations and other program issuances to ensure department is compliant.
Design, create and implement Quality Improvement processes to ensure optimal production with minimum errors. Monitor and report progress on a monthly basis.
Ensure that the Claims Processing department conforms to all applicable company regulations and requirements including, but not limited to, prompt payment to providers, Risk Adjuster submission and beneficiary reporting.
Enhance and maintain communication with all MA departments to maximize accuracy and efficiency in systems configuration, reimbursement uploads, enrollment processing as well as continuing maintenance of software used to facilitate claims processing.
Assist other departments in resolution of issues and development of procedures to “commit to quality” and to create a smooth, efficient flow of communication and processes to ensure the satisfaction of enrollees and providers.
Assist with the preparation of the annual budget and ensure that staffing within the Claims department is at appropriate levels, and within the approved budget, to accomplish the work of MA.
Ability to manage outsourced vendor relationships and oversee and audit functions per regulatory guidelines.
Manage, Recruit and Train Staff:
Oversee training of new employees along with an in-depth cross-training program for staffing flexibility
Educate to create understanding of our processes, operations and goals.
Promote an environment conducive to creativity and change.
Encourage interaction with other Medicare Advantage departments to promote teamwork and appropriate decision-making.
Monitor performance of the unit.
Develop standards and evaluate individual performance both informally and formally.
Provide feedback and growth opportunities.
Knowledge, Skills, and Abilities:
Outstanding leadership and a proven record of management accomplishments.
Very strong analytical and statistical process control skills.
Strong communication skills; interact well with all levels of the organization.
Strong follow-up skills.
Excellent team building skills.
Ability to delegate responsibilities
Strong personal computer skills including MS Office Suite and Internet savvy.
Ability to read, interpret and explain financial statements.
Excellent verbal and written communication skills to include formal document preparation and verbal presentation experience.
Strong organizational skills with emphasis on attention to detail.
Ability to work well under various stressful and time sensitive situations.
Ability to read, interpret and promulgate Federal registers and documents, as well as the Centers for Medicare and Medicare Services directives and regulations.
Knowledge of Medicare pricing methodologies including but not limited to fee schedules, DRG, CMG, DME, RUG, LTC-DRG, ESRD and others.
Knowledge of compliant claim coding and National and Local Claim Determinations
Demonstrated desire to “make it happen” in previous positions.
Knowledge of medical terminology, ICD9, HCPCS and CPT coding.
Education and Experience:
BA or BS in Business, Accounting or related field. Five or more years of management experience (preferably in a medical or insurance related position) may substitute for some or all of the formal education requirements.
Five or more years of progressively responsible supervisory or management positions in a healthcare payer production environment.
Desired:
Knowledge of Medicare Advantage program.
Knowledge of guidelines and standards for first dollar processing of Medicare claims.
Knowledge of claims processing flow and procedures including, but not limited to, coordination of benefits, provider and enrollment file functions, medical management, customer service, and quality improvement.
Please visit us on the web at www.frontlinesourcegroup.com
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Equal Opportunity Employer, M/F/V/D. Candidates must have authorization to work in the U.S. Clients will not sponsor visas.
Frontline Source Group™ is one of the fastest growing Information Technology, Accounting, Legal, Human Resources, Administrative, and Clerical staffing and direct hire firms with offices throughout Texas (Arlington, Austin, Dallas, Fort Worth, Plano, Houston Galleria, Lewisville, West Houston, San Antonio, Sugar Land, and The Woodlands), Tennessee (Nashville and Brentwood), and Arizona (Phoenix and Scottsdale).
Frontline specializes in matching top talent with companies for direct, contract, and contract-to-hire placements. We work with clients and candidates in all areas of the United States and Canada.