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Company

CareSource · 10 hours ago

REMOTE - Manager, Claims Performance Solutions - R8301

United States

Full-time

Remote

Mid, Senior Level

$80K/yr - $128K/yr

5+ years exp

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Comp. & Benefits

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Responsibilities

Provide expertise to team and departments in regards to claim adjustments, process automation, claim payment system, root cause analysis, and process development

Oversee and lead research of analysis of data in relation to claim adjustments and to draw conclusions to resolve issues as it relates to claim payments, denial, Facets payment methodology, and clinical edits

Responsible for understanding industry advancements in claims processing and automation and identifying opportunities to leverage efficiencies for claim adjustments Lead operational opportunities and recommendations for automation and process improvements

Review and analyze the effectiveness and efficiency of existing claims processes and systems, and participate in development of solutions to improve or further leverage these functions

Oversee claim adjustment tools (Mass Claim Adjustment, Robot Process Automation, scripts) to enhance capabilities, reliability, and quality of reprocessing through various methods

Oversee all claims regulatory reporting and prompt pay modeling

Responsible for all member and provider communications including claim letters/remittance advice and explanation code governance

Responsible for all post pay third party liability and direct billing

Ensure operational effectiveness by leading strategic and business planning, including business, financial, and operational goals and objectives definition as well as feasibility studies to develop and implementation of departmental policies and procedures

Ensure appropriate approvals, testing, and controls are in place and adhered to

Develop and implement ticket controls and ensure appropriate proper communication and approvals are in place prior to system implementation

Oversee and ensure that supporting business processes and documentation exists as a basis for system logic

Drive Best in Class technical claim handling within the Claim Adjustment process, development, techniques, and methods for claims payment

Lead initiatives with cross functional teams such as working with IT and others to automate claims functions and improve front end processes, implement new business including the design, testing and delivery of supporting processes to the business

Recognize and proactively manage scope and expected benefits across claims strategic initiatives and process improvements and is a key contributor to the claims technical advancements

Develop metrics and leading indicators to measure technical results and create/execute action plans as needed with other Operational Leaders

Ensure quantitative and qualitative measures are used to meet performance objectives

Implement opportunities for process improvement that impact operations, performance and quality

Track issues and status to ensure proper follow-up and coordination

Maintain project plans for all projects in which Process Development team is involved and ensure proper completion of those plans and escalation where timeframes will be changed

Participate in strategic planning and implement action plans

Review bulletins, newsletters, periodicals and attend workshops to stay abreast of current issues and trends, changes in laws and regulations governing claim reimbursement methodology, Business Process Automation (BPA), Robotic Process Automation (RPA), Facets User workshops, and any other industry events of value

Oversight of documenting process development and improvements, testing, and promotion of changes following established departmental change management processes

Development and maintenance of departmental change management process

Perform any other job duties as requested

Qualification

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Healthcare claims experienceClaims process automationRegulatory reporting knowledgeLeadership experienceRPA tools experienceMedical claims workflow knowledgeManaged care industry knowledgeMedical coding knowledgeAgile methodology familiarityMicrosoft Word proficiencyMicrosoft Excel proficiencyBusiness acumenTime management skills