Lead Managed Care Claims Validator

Since 1984, the CommuniCare Family of Companies has been committed to delivering exceptional person-centered care as a national leader in post-acute care for those that are chronically ill or have complex conditions.

Our more than 150 skilled nursing, assisted living, independent living, behavioral health, and long-term care facilities deliver sophisticated and transformative care to nearly 16,000 residents and patients at any given time. CommuniCare employs more than 19,000 employees across seven states (Ohio, Indiana, Maryland, Virginia, West Virginia, Pennsylvania, Missouri).

Due to continued growth, CommuniCare Health Services is currently recruiting a Lead Managed Care Claims Validator to lead our Corporate Claims Validation team.

PURPOSE/BELIEF STATEMENT

The Lead Managed Care Claims Validator must know how to perform all of the job duties and responsibilities of the Managed Care Validation team for both primary and secondary claims. This position supports the validation team and ensures compliance with the managed care claims expectations. Managed Care claims and billing are very complex and always changing. This position will provide ongoing guidance and training when there are changes to contracts, managed care rules and regulations, as well as coding changes or any CMS changes that impact managed care. The lead will be responsible for the support given with initial, ongoing, and ‘as needed’ training for validation staff, as well as developing training guides and manuals.

What We Offer

As a CommuniCare employee you will enjoy competitive wages and PTO plans. We offer full time employees a menu of benefit options from life and disability plans to medical, dental, and vision coverage from quality benefit carriers. We also offer 401(k) with employer match and Flexible Spending Accounts.

Job Duties/Responsibilities

• Carry a small caseload of their own to remain in active practice of managed care validation procedures and protocols.
• Directly supervise Managed Care Validation team.
• Monitor and evaluate validation process and procedures and make modifications as needed.
• Monitor the monthly validating process to ensure both timely and accurately submitted claims.
• Compile data for the revenue cycle team and divisions for any patterns or trends with late billing, rejections, or denials. First level of resolution to determine the issue for rejections or denials. Also responsible for identifying any barriers to timely billing and solutions to those barriers.
• Perform quarterly audits on the Corporate validation team to ensure they are following protocols and procedures for billing.
• Cover for biller if they are out or off.
• Remain up to date with all contract changes or additions to ensure information is relayed to the validation team.
• Help design, write, and implement any changes or new processes to the validation procedures.
• Work closely with the revenue cycle team member over both PCC and the Clearing house for issues that result in errors, warning, rejections, or denials that are not appropriate.
• Report dollars being billed each month, expected collections, and shortfalls for the 30 day bucket and summarize any obstacles that prevented the cash from being collected in the same month.
• Attend and participate in routine scheduled meetings within the CBO and the revenue cycle team.
• Identify efficiency opportunities within validation and getting claims on file with carriers for both primary and secondary claims.
• Attend, Participate, and/or Lead facility Educational In-services when appropriate.
• Attend all required in-service and training programs required within your department.
• Perform other related activities as assigned or requested.
• Promptly report any suspected resident financial abuse or billing fraud to supervisor immediately.
  
  

Qualifications/Experience Requirements

• High School graduate or GED required.
• Prior Work/Life experience, preferably in a long term care setting.
• Prior work/life experiences, preferably in a healthcare setting.
• Prior experience preferably with related software applications.
  
  

Knowledge/Skills/Abilities

• Knowledge of medical billing/collection practices.
• Must be knowledgeable of accounts receivable practices and procedures, as well as laws, regulations and guidelines that pertain to long term care.
• Must have a high degree of attention to detail.
• Must have the ability to make independent decisions when circumstances warrant such action, sense of urgency.
• Strong mathematical, written and verbal communication skills.
• Basic computer literacy and skills
• Strong organizational skills a must.
  
  

About Us

A family-owned company, we have grown to become one of the nation’s largest providers of post-acute care, which includes skilled nursing rehabilitation centers, long-term care centers, assisted living communities, independent rehabilitation centers, and long-term acute care hospitals (LTACH). Since 1984, we have provided superior, comprehensive management services for the development and management of adult living communities. We have a single job description at CommuniCare, "to reach out with our hearts and touch the hearts of others." Through this effort we create "Caring Communities" where staff, residents, clients, and family members care for and about one another.