Senior Claims Manager (REMOTE)

Location: Orange, CA

Pay Range: $106,000 to $140,000 DOE

The Sr. Claims Manager is responsible to work with Claim Supervisors for oversight of performance, compliance for claims, mailroom, and clerical functions for the Claims Department. Sr. Manager is responsible for coordinating efforts to ensure provider inquiries are resolved in a timely manner. Identify and adopts appropriate solutions and changes necessary to establish and maintain high levels of production, quality, service, and regulatory compliance.

Job Responsibilities

• Ensure Claims are adjudicated timely and accurately to assure conformity with internal, health plan, and regulatory guidelines and requirements.
• Create, monitor, and manage metrics and goals to ensure compliance with regulatory guidelines and maximize cost-effectiveness for the department, external vendors, and operational.
• Develop and implement operational strategy to reduce claims inventory, increase auto adjudication rate, improve quality, reduce cost of a claim, and maximize claims compliance efforts.
• Collaborate with other departments such as UM, CM, Pharmacy, Eligibility, Performance Programs, Compliance, Configuration, Network Management IT Ops to drive operational excellence, including but limited to identification and implementation of Auto-adjudication rules, claims pend rules, claims editing rules and authorization rules.
• Recommend changes for system design, rules, and workflows affecting the assigned departments.
• Recruit, develop, motivate, and help lead the Claims Department to continuously improve operational performance.
• Develop goals and objectives for the department and rollout strategy to obtain the established business outcome.
• Sr. Manager is responsible for several reports on a weekly, monthly, and quarterly basis. Ensure weekly, monthly, and quarterly reports are generated timely. Review reports with Director and ensures accurate data is reported to management.
• Recommends policies and procedure changes regarding claim payment processing.
• Consistently monitor goals with special emphasis on quality and completion of claims processing within the regulatory guidelines.
• Oversight of the day-to-day claims inventory to ensure all CMS and DMHC regulatory guidelines are met.

Qualifications

Minimum Education:

• Bachelor’s Degree or equivalent experience required. Bachelor’s Degree preferred with healthcare administration focus.

Minimum Experience:

• Five to seven (5 – 7) years prior medical claims processing experience required. Healthcare experience preferred.