Senior Manager, Claims Operations Support / Job Req 688166915

PRINCIPAL RESPONSIBILITIES:

Under general direction from the Director, Claims, the Senior Manager, Claims Operations Support is responsible for the management and oversight of the Claims Operations Support function which includes, but is not limited to, research and resolution of claim payment issues, auditing, refund processing and claims system analysis/testing activities; the Provider Dispute Resolution (PDR) function; and the Other Health Coverage/Third Party Liability (OHC/TPL) function.

The Senior Manager, Claims Operations Support is responsible for ensuring that processed claims are reviewed and audited to assess work performance by the Claims Processing staff and identifying training needs and opportunities for workflow and system configuration improvements. The Senior Manager works closely with the Manager, Claims Production and the Applications & Configuration department to identify the root cause of processing or system issues that impact the claims processing function and recommends solutions. The Senior Manager oversees the staff responsible for the User Acceptance Testing (UAT) of all system functionality for new and existing products and coordinates and signs off on all UAT activities. The Senior Manager receives and responds to requests related to complex provider claim issues from the Provider Services department in a timely and accurate manner and continually communicates and enforces department goals and objectives within a total quality management approach and in compliance with all applicable state/federal regulations. The Senior Manager will work closely with the Director, Claims and the Manager, Claims Production to identify training needs based on errors identified through Service Requests, Refund Checks or PDRs and will assist the department's leadership team in monitoring and enforcing production and quality standards, ensuring compliance with all operating policies and procedures and claims processing guidelines, and collaborating with other departments to ensure the Alliance's business, operating and reporting goals are met. The Senior Manager will oversee the OHC/TPL staff to ensure all recoveries are recognized and reported to DHCS, as required, as well as providing guidance to staff for any TPL-related activities.

Other principal responsibilities include:

• Provide oversight of Claim Specialists and PDR staff and provide day-to-day supervision of the OHC/TPL Coordinator.
• Work with the Claims Director to develop and implement production goals.
• Work with the PDR Supervisor and Claims Specialist Supervisor who are responsible to assign and monitor daily workloads to ensure goals are achieved.
• Oversee and/or prepare routine and ad hoc reports.
• Respond to escalated provider claim inquiries by telephone or correspondence, as needed.
• Provide advice to other Alliance departments on claims related issues by phone, email or in person.
• Prepare, review, and approve staff timecards, approve/deny requested time off, and monitor attendance.
• Hire, coach and develop staff to accomplish organizational objectives.
• Monitor and provide feedback on staff performance, recognizing strengths and coaching towards improved performance where necessary.
• Implement corrective action plans and discipline as necessary.
• Conduct scheduled performance appraisals in a timely and thoughtful manner.
• Conduct weekly one-on-one meetings with direct reports.
• Review Inventory, Quality and Production reports weekly.
• Review and improve Service Request workflow. Suggest improvements to current departmental workflows and systems.
• Track and perform root cause analysis for Service Request payment issues, Refund Checks and PDRs; implement corrections to address the root cause.
• Monitor PDRs to ensure regulatory requirements are met.
• Monitor Service Requests, Refund Checks and adjustment projects to ensure timely completion.
• Manage all system testing activities related to new software implementation, system upgrades or routine system configuration changes.
• Ensure that the Department adheres to all state and federal regulations, contract requirements, and service level agreements.
• Assist in the preparation for all internal, external and regulatory audits.
• Represent the Alliance during internal or exernal audits of Alliance claims processing.
• Provide oversight of claims and PDR audits for AAH delegated groups.
• Oversee the TPL/OHC Coordinator to meet both TPL and OHC data collection and ensure mandated turnaround times for response are met accurately and completely.
• Oversee reconciliation of Share of Cost (SOC) collection by Providers as indicated on claims and eligibility records.
• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Hire, train, lead and evaluate staff; build an effective team and assist in ensuring appropriate staffing and staff development.
• Identify problems, perform appropriate analysis and determine options for resolution
• Collect needed data, information and/or analyses to assist in resolving PDRs, complex claims issues and/or large volume claim adjustment projects.
• Produce reports on daily, weekly, monthly and/or an ad hoc basis.
• Communicate effectively and efficiently, internally and externally, in written and verbal formats.
• Ensure system configuration changes are producing the expected results by conducting post-production audits.
• Respond to inquiries from other Alliance departments on claims related issues via phone, email, remote meetings or in person.
• Lead and/or participate in internal committees and meetings.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Constant use of telephone headset.
• Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various other objects weighing between 0 and 20 pounds.
• Frequent walking and standing.

Number of Employees Supervised: 10-15

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• High School Diploma or GED required.
• Bachelor's degree preferred or combination of education and equivalent work experience.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Seven years in a medical claim-processing environment, preferably in Managed Care.
• Five years' experience with Medi-Cal guidelines and claims processing applications required, including experience with all types of claims (professional, ancillary, facility)
• Five plus years' experience handling complicated claims issues required (manual pricing, late interest payment calculations, COB, adjusting previously processed claims, etc.).
• Four years' experience reviewing and responding to disputes from providers and/or members required.
• Five years' experience in a Manager, Supervisor, Trainer, Quality Assurance or Auditor role highly preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Must have detailed knowledge of CPT, HCPCS, RVS, ICD-10, CMS1500/UB04 coding and forms.
• Must have detailed knowledge of Provider Dispute Resolution function.
• Experience with HIPAA and EDI transaction processing required.
• Previous experience as a Manager, Supervisor, Trainer or Auditor in a claims environment desired.
• Excellent leadership, organizational, verbal and written communication skills, and problem solving skills.
• Excellent customer service skills.
• A "hands-on" leader.
• Experience with claims auditing.
• Ability to develop, monitor and adjust production standards.
• Well organized and detail oriented.
• Ability to handle multiple projects and balance competing priorities.
• Previous experience in a high-volume electronic claims processing system.
• Experience in use of various computer system software, including Microsoft Office products.
• Prior claims processing experience in RAM HealthSuite a plus.

SALARY RANGE $136,119.77-$204,179.66 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.