Capital Rx · 1 day ago

Claims Adjudication Manager

United States

Full-time

Remote

Mid, Senior Level

5+ years exp

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Responsibilities

Review, assess, and make decisions on medical claims submitted by networks, claimants, or other parties.

The Claims Adjudicator reviews the facts of each case and applies the applicable laws, regulations, and policy provisions to determine the appropriate claim outcome.

The Claims Adjudicator must be knowledgeable of the claims process, laws, and policies, as well as possess excellent communication skills and a commitment to providing outstanding customer service.

The Claims Adjudication manager will be responsible for direct reports, and developing workflows, policies, and procedures related to the claims adjudication process.

Manually adjudicate claims received via 837 EDI file, HIPAA 1500 or UB-04 forms, or direct member reimbursement submissions via superbill submission

Configure, test and validate Medical Adjudication workflows

Build and maintain trusting relationships with clients through superior customer service. Provide oversight of future network integrations and client implementation.

Accountable for accurate and timely transition of new clients into the JUDI platform.

Lead communications throughout the implementation process, including detailed and strategic guidance for adjudication infrastructure, processing, reporting, inquiry management, and complex claim situations/requests.

Proactively identify execution risks and mitigation strategies.

Provide ongoing stakeholder support to troubleshooting inquiries.

Understand and manage requests for new features in alignment with the product roadmap.

Partner with product managers and directors operating in an agile framework to conceptualize and break down functional and non-functional requirements needed to adhere to all contractual and federal payments regulations.

Identify and drive efficiencies to automate adjudication flows and reduce risk.

Certain times of year may require meeting participation, service support or other requirements outside of standard business hours, including weekends.

Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Claims AdjudicationMedical Payments ExperienceTeam Management837 EDI Files835 EDI FilesBenefit DeterminationsClaims Processing KnowledgeProject ManagementMicrosoft Office SuiteJiraMiroConfluenceGithubAWS RedshiftMedicare ExperienceMedicaid Experience