WellSense Health Plan · 3 hours ago
Manager of Claims
Boston, MA
Contract
Remote
Mid, Senior Level
5+ years exp
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Responsibilities
Responsible for day-to-day management of the Claims Department function.
Manages staff development, work standards and recruits, motivates and retains a high caliber team to ensure efficient operation of all claims functions.
Collaborates with training and quality resources to provide on-going training for staff which includes performance coaching.
Establishes and maintains standards of performance for productivity, quality and claims turnaround. Adjusts such standards when necessary due to processing system enhancements, streamlined workflows or other production efficiencies.
Provides feedback, suggestions, status updates to department leaders regarding improvement initiatives and opportunities. Provides input into development of the department budget and manages and controls expenses while meeting operations requirements.
Monitors relevant daily and weekly claims status reports, levels of service, transaction receipts, productivity, and quality to identify performance gaps. Takes corrective action and follows up to ensure positive outcomes and goals are achieved.
Develops and documents workflows, business policies, practices and procedures to ensure quality and consistency
Obtains and maintains a complete understanding of the Facets system
As appropriate and/or assigned, the Claims Manager is responsible for the preparation and research of data and records as well as associated reports required to meet internal and external audit and regulatory requirements.
Communicates details and provides examples of provider billing problems, contracting, coding, member and IT issues to the appropriate departments in a timely fashion and works with these organizations to resolve such issues.
Identifies, communicates, and escalates issues to the Director of Claims, Enrollment and Provider Appeals on a timely basis.
Coordinates resources to ensure that projects have sufficient means to meet/exceed expectations. Maintains and attends regular meeting scheduled with other functional departments to identify any processing system issues that negatively impact claims productivity and/or quality, review procedures, and resolve issues. Ensures that all IT system changes that affect service levels and processing are thoroughly tested before being incorporated into the live environment.
Maintains current knowledge of provider network development and contract issues, applicable State and Federal policies and regulations, as well as industry standards for claims adjudication issues. Ensures that these issues are captured in training and reference materials as well as policy & procedure documents.
Expected to take on and complete any other assignments outside of the regular duties for this position when assigned by management.
Qualification
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Required
Bachelor’s degree or the equivalent combination of education, training and relevant work experience, usually 6-7 years related experience in a managed care plan.
Minimum of 5 years of claims operations experience required
Previous experience supervising/managing staff
Successful completion of pre-employment background check
Detail oriented, organized, and possesses demonstrated leadership skills along with excellent verbal and written communication skills.
Ability to apply independent and critical thinking to solve complex problems
Excellent interpersonal skills are required to effectively develop and maintain strong working relationships with internal and external colleagues.
Proficiency in the use of Microsoft Office products such as Word, Excel, PowerPoint and Outlook required. Experience with Facets highly desirable.
Working knowledge of claims processing systems, CPT-4 and ICD-10 coding, and relevant State and Federal regulations
Excellent organizational skills and attention to detail.
Ability to multi-task, prioritize and work independently
Ability to initiate and drive change; demonstrated results-driven approach
Demonstrated ability to work independently and manage multiple complex projects simultaneously.
Proactive, motivated, and a collaborative team player.
Demonstrated ability to adapt quickly to changing priorities.
Preferred
Minimum of 5 years of experience at the supervisor and/or manager level strongly preferred
Minimum of 5 years of experience working for a managed care plan preferred
Facets experience is strongly preferred
Medicaid and Medicare managed care experience preferred
Claims billing experience working for a provider is preferred
Some knowledge of CMS regulations preferred
Benefits
Full-time remote work
Competitive salaries
Excellent benefits
Company
WellSense Health Plan
A nonprofit health plan serving Medicare, Individual & Family, and Medicaid plan members in Massachusetts & New Hampshire.
1,001-5,000 employees
Funding
Current Stage
Late StageLeadership Team
Heather Thiltgen
President & CEO
Diana Cruz
Chief Operating Officer
Company data provided by crunchbase
