Job Abstract

The Manager, Claims directs the efforts of others in the achievement of the strategic, regulatory and operational objectives of the Health Plan. Provides direct supervision to a team of claims examiners, data entry clerks and claims assistants and continuously monitors department for compliance with regulatory requirements. Ensures all work performed within the claims department is of the highest quality and is well documented. Works with the Claims Director, Claims Managers and Supervisors to ensure the Plan’s core system produces a high level of claims auto adjudication. Develops policies and guidelines that ensure work activities are effective and well documented. Works with supervisors and department managers to develop procedural changes to improve results. Uses a variety of data analysis tools and methodologies; applies independent judgment to solve systematic problems. Recommends actions and regularly exercises discretion in regard to key business processes within the team. Develops an understanding of internal operations and how related teams interact to achieve results. Demonstrates professional courtesy and represents the company in a positive manner in all areas of internal and external communications. Responsible for appropriate record keeping, required reports, and ensuring related administrative functions are correct and maintained. The Manager must have the ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims. The Manager must demonstrate leadership and interpersonal communication skills by working collaboratively and effectively with peers, superiors and subordinates to accomplish objectives. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Provide an environment that allows staff members to flourish in their work duties. Quality levels of 99% maintained throughout the department. Continuous training of staff on all enhancements and updates to claims regulations and company policies. Develop procedure changes to improve results. Corrective action plans developed and implemented to remediate.

Maintain quality goals and production levels within the Department. Working with department supervisors, ensures that production goals associated with each work area are consistently met and that supervisors receive mentoring as appropriate to ensure department goals are met.

Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of L.A. Care. Claims examiners and auditors are utilizing authorized procedures that are well documented and meet the business needs of L.A. Care. All procedures meet applicable regulatory requirements.

Ability to track and trend the metrics associated with the examiner and auditor production and prepare and present written and verbal reports. Ability to research complex problem areas within the department or within the systems used by department, identify the root cause of these issues and recommend corrective actions. Continuous monitoring of work performed within the claims department. The Manager must have the ability to research problems of a complex nature and create clear and concise documentation. The Manager must work collaboratively with peers throughout the company to achieve the goals of the company. The Manager must provide mentoring to supervisors and Claims department staff ensuring that they are working effectively and meeting quality and production goals. Use data analysis and independent judgment to improve processes within the department.

Provide an environment that engages staff to fully participate in the overall functioning of the unit. The Department flourishes under the leadership of the Manager producing high quality work in a high production environment.

Required:

At least 5-7 years of Claims Management experience.

At least 3-4 years of supervisory/management experience.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Demonstrated depth of knowledge and experience in processing Health Plan claims of a complex nature.

Advanced working knowledge of claims coding and medical terminology.

An in-depth knowledge of claims code sets including but not limited to ICD9, ICD10, HCPCS, DRG, APC and other inpatient and outpatient coding systems.

An advanced knowledge of contractual pricing mechanisms for inpatient, outpatient, Long Term Care (LTC) and ancillary services.

Must have an in-depth understanding of the application of Division of Financial Responsibility (DOFR) to claims processing.

Extensive experience working with COB and TPL claims in a managed care setting.

Must be highly experienced in interpreting complex contractual terms with Providers, Facilities, Plan Partners, delegated groups and related contractual scenarios.

Required:
Solid understanding of standard claims processing systems and claims data analysis.

Extensive experience in overseeing and monitoring the timeliness and accurate processing of claims.