Claims Manager

Title: Manager of Claims

Summary: The Manager of Claims position is a key part of the department’s successful operation. This position has direct responsibility for all Commercial and Native American Claims Operations.  The Manager of Claims is a senior level member of the organization, who is monitoring, supporting, and instigating action to improve, when necessary, the day to day productivity of claims operations within the company. The Manager of Claims will work with the Director of Claims to establish the strategic planning of all Claims payment resources for the corporation. This position reports directly to the Director of Claims and is responsible for Commercial, Governmental and Native American Tribe Divisions. The Manager of Claims interacts with clients, providers, members; team associates and must possess the skill to coordinate work issues within each of the departments that report to them. As a Manager it is critical to create leadership and be able to develop each team member. The ability to be organized, accurate, and efficient and communicate well with others is necessary skills for this position.  This position requires extensive use of Trizetto/Rims, Excel, and Word.  Good attendance, positive attitude, acceptable production and operational results are critical to the success of the position. The Manager of Claims,  interfacing with the Management team, exercises fiduciary and managerial responsibility over the entire claims area and interfaces with internal  resources in a prudent and ethical manner. 

The Manager of Claims works with the DOO to empower staff growth, and client retention, ensuring the organization’s prosperity. 

Essential Duties and Responsibilities: include the following. Other duties may be assigned.

•    Develops and maintains all staff schedules along with the Director to appropriately service our contract requirements.

•    Assists with hiring and training all new team members.

•    Assists or completes team member reviews.

•    Performs or ensures appropriate performance management of staff occurs timely and accurately. 

•    Coordinates with Plan Builders to test and assure all plans are built to client document specification

 Assists in setting production goals. Will regularly monitor results and communicate them to the team members, notifying the Director of Claims when a team member is not meeting expected results.

•    Processes claims as needed to assist with production goals.

•    Reviews and evaluates all Claims Operations functions and assures uniform and documented processes, and management strategies are in place.

•    Assures short term and long-range planning for all functions of the claims department are performed for the well-being of the corporation and its client base.

Oversees and provides counsel to each member of the Claims Team as they make decisions that affect day-to-day operations and make recommendations for changes in strategies, plans, and policies for the unit. 

Promotes an environment that encourages collaboration and creativity to advance collaborative efforts within each operational unit. Maintains and encourages open communication among the various teams within the organization. 

•    Works collaboratively with senior executives, and key personnel in the formulation and implementation of company policies, standardized procedures, and decisions affecting our client base. 

•    Holds responsibility for all claim production and assures the company of appropriate quantity and quality.

•    Coordinates all Claims units to assure the most current version and operation of the claims system and other supporting systems are in use for the operations of the organization.

•    Works hand in hand with the IT department. 

Keeps abreast of all emerging system activities as it relates to our current claims system in order to assure efficiencies in the department and determines the appropriate resources needed to respond to any increased workload.

•    Supports the Sales staff and senior management as needed. 

Prepares monthly reports which reviews the effectiveness our Claims Unit, as it relates to the production and turnaround of our clients claims, and provides reasonable assurance that operations are cost effective and efficient and client and company assets are safeguarded. 

Coordinates the training of new Claims staff and determines, in conjunction with the Director of Claims and the COO, the appropriate staffing level and skill level requirements for the unit. 

•    Assures all Claims processing procedures meets or exceeds the data security standards set by HIPAA and/or our government clients. 

•    Manages, reviews, file structure to assure system flows/links are appropriate and working.  Creates work flows to document system processes.

•    Assures and maintains the integrity of Claims processing and claims products sold and used for Capitol business

•    Coordinates all audits for the claims departments and reports results to all Managers, Directors and COO as needed.  

•    Assures all performance guarantees are met and reported on as needed by each client and communicates results internally.

•    Uses the audit function to track training need of all staff related to the claims units.

Works with the Director of Claims and in coordination with the Claims Specialty teams, not limited to, but to include, adjustments, prior authorizations, case management, corrections, voids, appeals and stop loss filings.

•    Coordinates with Plan Builders to test and assure all plans are built to client document specification.

•    Develops, maintains and monitors job descriptions as it relates to each unit within the claims department, in coordination with HR.

•    Works with the Technical Services area to support and build the ability to auto adjudicate claims as appropriate to the client.  

•    Coordinates and works with all Account Managers, as needed. 

•    Monitors and controls all outside vendors, in conjunction with the COO,  contracted to support claims processing.

•    Determines and plans future needs and strategies as it relates to claim system operations.

Manages all Front End solutions to the Claims system and incoming documents including the mail room and scanning.
Reviews and determines policy and procedure for this function and determines the scope of responsibilities whether internal or external.

•    Regular, predictable attendance is required.

•    Ability to get along and work effectively with others.

Supervisory Responsibilities: Directly supervises employees in the claims department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Measures of Performance: The Manager of Claims shall be considered to be performing in an acceptable manner when the following have been accomplished:

1. Problem Solving – Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

2. Customer Service – Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.

3. Interpersonal Skills – Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.

4. Oral Communication – Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Tailors the content of speech to the level and experience of the audience; Uses appropriate grammar and choice of words in oral speech; Organizes ideas clearly in oral speech; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.

5. Written Communication – Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

6. Teamwork – Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed; Listens and responds constructively to other team members’ ideas; Offers support for others’ ideas and proposals; Is open with other team members about his/her concerns; Expresses disagreement constructively.

7. Quality Management – Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.

8. Delegation – Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results.

9. Leadership – Exhibits confidence in self and others; Inspires and motivates others to perform well; Effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others.

10. Managing People – Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products and services.; Continually works to improve supervisory skills.

11. Ethics – Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

12. Judgment – Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.

13. Quantity – Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.

14. Attendance/Punctuality – Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

15. Dependability – Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience: Bachelor’s degree (B.A.) from four-year college or university; or four to five years related experience and/or training; or equivalent combination of education and experience.

Language Skills: Ability to read and interpret documents such as operating manuals, instructions and procedure manuals.  Ability to write routine reports, and correspondence. Ability to speak effectively before groups of customers or employees of the company.

Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form..

Computer Skills: To perform this job successfully, an individual should have knowledge of Internet software and the Microsoft Office Suite of products, including Access and the ability to manipulate data. Knowledge of basic office equipment should include: Internet and email, copy and fax machines, postage meter and telephone.            

Physical and Emotional Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The inability to cope with a stressful work environment does not constitute a protected disability.

Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, and talk or hear. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

The noise level in the work environment is usually very quiet.

Acknowledgements: I have reviewed and understand the above job description and believe it to be accurate and complete.  
I also understand that the company retains the right to change this job description at any time. I also understand that this job description is not a contract for work.