Job Description

To supervise, monitor and evaluate the needs and objectives of claims department in in the area of production in order to ascertain that company directives and goals are being met.  Ensures the claims process from claims creation, adjudication to claims EOP flows successfully.

Essential Functions & Responsibilities

• Supervise, monitor and coach the claims production management team and their staff in their daily responsibilities.
  • Claims Run Management
  • Claims Adjudication/Processing
  • Claims Payment Processing
• Answers and resolves claims operational problems and issues that arise during the companies daily activities.
• Maintain working knowledge of all systems used in the adjudication of claims.
• Monitor the Productivity and Quality of the claims staff to ensure adherence to requirements are being met
• Uphold claims turn around times to ensure that contractual, federal and statutory requirements are being met.
• Report to the Director of Claims Production any areas requiring attention.
• Assists in the maintaining of appropriate staffing in order to ensure contractual and departmental expectations are met.
• Review claims processing system limitations and operational flows and propose alternative methods of resolution to the Director of Claims Production.
• Review system enhancements for the claims adjudication systems to ensure proper systemic functionality.
• Maintain excellent working relationships with all inner claims department management and external claims department personnel in order to maintain successful process flow.
• Interview, hire and evaluate new employees in the claims department.
• Creates claims runs and assigns the claims runs to the appropriate claims staff.
• Creation of finance payment files for purposes of provider claims payment.
• Coordination with Finance and IT on resulting payment files.
• Assists in the training of new employees in the claims department.
• Completes annual reviews of direct reports and reviews the claims examiners reviews.

Required Education and Experience

• Bachelor’s degree or 8 years equivalent work experience in a managerial role.
• Minimum 10 years experience in a medical office claims environment with increasing levels of responsibility.
• Strong interpersonal communication skills in English. (both written & verbal)
• Spanish communication skills helpful but not necessary.
• Demonstrated knowledge of ICD-9, ICD-10, CPT-4 and HCPCS coding.
• Demonstrated knowledge of Medicare, Medicaid and Commercial lines of business claims adjudication rules.