Claims Manager - Health Plan Adjudication Operations

 THIS POSITION REQUIRES WASHINGTON STATE RESIDENCY

Employees must establish a residence in Washington State within 30 days of their first day of employment and must maintain a residence in Washington State during their employment with PSW.  If a position is eligible to telework, work performed while teleworking must be performed in Washington State.

Summary / Objective:

The Claims Manager is responsible for managing the daily operations of the PSW claims adjudicators and claims department. Reporting to the Director of Payer Operations, the Claims Manager is responsible for development and implementation of the strategic plan and objectives for PSW as they relate to claims processing services and evaluating the accuracy of processing performed by other organizations for whom the PSW organization has assumed financial risk but has not been delegated to process the claims.  This includes planning, development of policies and procedures, budgeting, quality monitoring, improving efficiency of processes, and increasing claims automation while meeting regulatory guidelines.  Focusing on staff development, with the ability to foster and build a team environment is essential.  

Essential Functions:

• • Using knowledge of Medicare Guidelines, ASA, RVS, CPT, DRG, HCPCS, RBRVS, ICD-10, Redbook, UB-04 Codes, must be able to initiate, coordinate, train, and monitor departmental staff on tasks for timely claims payment processing, entering and auditing requirements to meet departmental and regulatory needs.
  • Works closely with management teams of PSW and health plans to assure accurate and timely adjudication of claims, including reprocessing as needed, coordination with other payors as needed, filing for TPL and reinsurance, auditing of claims processing, and accuracy of data and development of appropriate reports and other tools. Lead by example using a hands-on approach to management and an open-door policy. Manage, train and empower team members; meet regularly to discuss objectives, observations, progress and results achieved.
  • Develops training materials and methodology by which new and existing employees are initially oriented to their responsibilities and acquire advanced knowledge to improve their performance over time.
  • Develops departmental policies and procedures and policy interpretations on behalf of PSW. Assists in health plan management in assuring consistency in claims processing among the organizations delegated for claims processing functions.
  • Audits claims data processed by other entities for accuracy and to confirm the appropriateness of financial settlements between and among PSW and its health plans.
  • Develop and implementing performance standards within the department for claims processing and payment to assure accuracy, timeliness and competency.
  • Interprets health plan benefits in conjunction with hospital and professional contract specifications and assures adjudication and reimbursement are done accordingly.
  • Monitor team member performance, training needs and ensure duties are carried out as per company policy, job descriptions and Health Care regulations. Modify leadership style to meet situational requirements. Identify strengths and weaknesses and provide timely feedback to the individual.
  • In conjunction with the Claims Supervisor, monitor staffing levels and communicate staffing needs to the Director; make recommendations as needed.
  • Collaborates with Director of Operations to prepare department budget, develop mechanisms for staff development and makes appropriate changes as needed to keep Department current with new regulations policies and trends.
  • Collaborates with MA Program Manager and Sr. Claim System Specialist to identify, analyze, and implement strategies to overcome operational challenges facing the claims department.
  • Provides direction to the Sr. Claim System Specialist regarding claims project prioritization, system configuration, and other duties as assigned.
  • Collaborates with both internal and external healthcare team members to develop and implement strategies related to clinical and administrative goals. Communicate them to team members and provide leadership to help achieve desired outcomes.
  • Responsible for bi-weekly resolution of time sheet details resolving any accuracy deficits, approving and submitting to HR for payroll processing for claims team staff.
  • Establishes production quality and quantity performance measurements for claims department staff. Provides at minimum quarterly reports to claims team members on individual and claims team production based on these performance measurements.
  • Reviews claims processing methods and procedures, recommending and upon approval, if required, instituting changes to improve efficiency of operations.
  • Responsible for explaining and enforcing policies and procedures in relation to claims adjudication. Assists in the interpretation of Medicare regulations, health plan policies and procedures, and recommends and drafts associated internal policies and procedures based on these interpretations.
  • Serves as content resource for claims adjudication issues, and is available within the claims team and to staff in other departments for questions, planning, and problem resolution including impact assessments.
  • Maintains primary accountability in the performance of processing all refunds, reversals, reconsiderations and finalization of claims following health plan appeals.
  • With input from Director, prepares and presents periodic performance reviews for claims staff consistent with objective evaluation of performance standards. Collaborates in development of performance goals for the following year, and provides input as to whether salary adjustment is warranted. Continuously encourage staff to improve their knowledge and skill levels and provides training as necessary.
  • Maintains a positive working atmosphere and intervenes as necessary promote positive employee relations. May offer suggestions to staff to improve performance, and may verbally counsel employees whose performance is not at standard to assure that they are aware of what is expected.  Such verbal counseling must be added to employee file.
  • Prepares the monthly health plan turn-around time reporting (Compliance reports). Assists in preparation of ad-hoc reporting as necessary.
  • Determines appropriate staffing levels to assure timely and accurate processing of all claims. Hires, evaluates and supervises development of subordinate staff.  In consultation with Director of Operations, implements progressive discipline action including termination of employment.
  • Continue own education by staying informed of industry trends and actively participating in trainings provided by the company.
  • Ensures compliance with PSW policies and procedures with special emphasis on compliance with HIPAA requirements.

Knowledge/Skills/Abilities:

• Team Leadership: Provide consistent leadership, promoting professional work standards, good teamwork, empowerment, and open communication. Work to engender trust, honoring confidentiality.
• Must be able to manage, organize, supervise and provide efficient leadership for a team comprised of 5-8 team members.
• Building Collaborative Relationships: strong interpersonal skills and has the ability to build strong relationships at all levels. As unique situations arise, position must be sensitive to company needs as well as customer needs.
• Problem Solving and Resolution: Strong follow through, quick decision making abilities and able to problem-solve in a fast pace environment. Engages with direct reports to solve problems and create solutions.
• Project Management: Provide direction, coordination and ongoing evaluation of the operation and projects/tasks. Helps team stay focused on priorities while managing multiple directives.
• Organizational Skills: Plan, schedule and direct work of self and others while balancing the needs of the operation.
• Excellent verbal and written communication skills, including ability to effectively communicate with internal and external customers including active listening, professional verbiage and written correspondence.