Claims Director directs and oversees the operations of an insurance claims department to meet operational, financial, and service requirements. Establishes policies and procedures for the administration of insurance claims for personal, property, or casualty loss based on coverage, appraisal, and verifiable damage. Being a Claims Director is responsible for the strategic processing and payment of claims. Maintains up-to-date- knowledge of legislation, regulations, and industry events which pertain to insurance claims. Additionally, Claims Director provides expert guidance and consultation to staff on the most complex claims. Requires a bachelor's degree. Typically reports to top management. The Claims Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. To be a Claims Director typically requires 5+ years of managerial experience. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. (Copyright 2024 Salary.com)
Job Summary:
The Claims Analyst is responsible for monitoring liability claims, verifying and updating information on submitted claims. Reviews contract information and policies to determine which charges are eligible for reimbursement. Ensures completeness and accuracy with claims processing in order to support the organization’s revenue cycle.
Essential Job Function:
•Reviews claims and appeals for accuracy, completeness, and eligibility.
•Analyze and audit claims to ensure compliance and provide solutions to resolve claims errors.
•Creates financial estimates on a weekly basis using Microsoft Excel.
•Provides feedback and justification of denied claims to providers, as needed.
•Aids providers on how to submit claims and verification of participant’s eligibility.
•Conducts basic contract review to confirm payment rates.
•Collaborates with other departments in the organization.
•Requests monthly inventory tracker from TPA (Third Party Administrator)
•Conducts follow-up activity for claims held until the claim is closed.
•Confirms that claims are associated with pre-authorizations from the Interdisciplinary Team (IDT) and/or Primary Care Provider.
•Conducts coordination of benefits, insuring that claims impact primary and secondary insurance, as appropriate.
•Reviews and analyzes claims loss, expense reserves and reconciles claims reports with authorization sheets.
•Processes new claims and disseminates the claims to TPA.
•Reports claims issues to IDT, Primary Care Providers, Vice President of Finance and other entities, as appropriate.
•Assists Claims Supervisor to identify exposures to the company and reports to senior-level management on pending claims and litigation that may have an adverse impact on corporate goals.
•Assists Claims Supervisor as a liaison between the TPA, provider network, insurance companies and other entities as needed.
•Checking pricing of claims through contracted rates and Medicare/Medicaid fee schedules.
•Demonstrates workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high quality care and patient-centeredness.
•Attend and participate in staff meetings, in-services, projects, and committees as assigned.
•Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
•Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
•Be flexible in schedule of hours worked.
•May require use of personal vehicle.
Knowledge, Skills and Abilities
Requirements
Qualifications
•A minimum of a High School Diploma with two (2) years of relevant experience required.
•A Bachelor’s degree preferred.
•2 years of professional experience processing and analyzing claims is strongly preferred
•Ability to present information in one-on-one and group settings.
•Ability to communicate information in a professional and confident manner.
•Demonstrated ability in critical thinking, self-initiative, and self-direction.
•Understanding of physiology, medical terminology, and disease process. strongly preferred.
•Demonstrated PC skills in Word, Excel, and Microsoft Access
•Detail oriented
Job Type: Full-time
Pay: $19.00 - $25.00 per hour
Expected hours: 40 per week
Benefits:
Schedule:
Work setting:
Education:
Experience:
Ability to Relocate:
Work Location: Hybrid remote in Bakersfield, CA 93305
Clear All
0 Claims Director jobs found in Bakersfield, CA area