Job Abstract

The Manager, Claims Integrity Provider Remediation is responsible for development and implementation of methods to accurately and timely review provider escalations, inquiries, logs or other submissions.  This position will work to best coordinate efforts across the Claims Integrity departments ensuring the highest level of quality responses to all stakeholders.  This position will manage a team dedicated to maintaining constant communication, consistent quality, and root cause identification and resolution for provider cases. This position manages all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Manages provider escalations, inquiries, logs or additional submissions to accurately and timely respond to all stakeholders.  Monitors inventory to ensure prompt resolution while maintaining all regulatory requirements and timely escalation of areas close to non-compliance.  Oversees preparation of summaries and reports for related tasks for both internal and external teams.

Oversees team in day to day operations to include timely and accurate response on all Provider Inquiries while assisting with resolution of higher complex cases.  Meets with team regularly to detail project assignments, ensure accountability, review quality and work metrics. Manages team development and direct support to include training, performance standards, and process improvements.

Provides subject matter expertise, meets with Director and other Management to collaborate on provider meetings, ensuring all communications are clear, concise and accurate.  Applies Medi-Cal and/or Medicare policies and procedures within healthcare operations.   Stays abreast of all regulatory and/or contractual changes and the impact of these changes to provider escalated issues.

Supports the Director and other Management with development of department policies and procedures, workflows, training documents, etc.  Consults with Claims Integrity team in making recommendations to management on operational issues.

Fosters and maintains a great place to work by communicating clear roles and responsibilities and building successful working relationships across Claims Integrity.

Manages staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Performs other duties as assigned.

Required:
At least 5-7 years of experience related to Claims, Appeals and grievances, disputes, etc.

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.

Preferred:
Provider Dispute Resolution experience.

Required:
Extensive knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously; strong attention to detail.

Knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.

Excellent interpersonal, verbal, and written communication skills.

Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.

Must be able to present findings to various levels of management, and including stakeholders, across all organization.

Preferred:
Ability to review claims in 360-degree approach.