Medicare Advantage Claims Lead - REMOTE (Updated: 10/5/2023 9:04:26 AM)
This job leads and manages the claims delegation and oversight function along with claims processing reviews and issue resolution function within the organization's health plan in accordance with established plans, standard operating procedures, and legal and regulatory requirements. Collaborates with the leadership team to inform strategy and ensure the operational effectiveness, financial success, and ongoing implementation of strategic goals and priorities. Works with the entire health plan team to investigate and resolve high level claims issues. Develops, implements, and monitors policies and procedures, executes on-going claims reviews while developing an in-depth understanding of the Facets claim system.
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 qualified individuals with disabilities to perform the essential duties.
This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company’s discretion.
Education
Required - High School diploma or equivalent.
Preferred – Bachelor’s degree in business or healthcare administration.
Work Experience
Required – 5 years Medicare Advantage claims issue resolution, review and claims delegation oversight.
Preferred – Experience with Facets claim system.
Certifications
Required - Certified Professional Coder.
Knowledge Skills and Abilities (KSAs)
• Proficiency in using computers, software, and web-based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally.
• Knowledge of Medicare Advantage Claims Processing guidelines, claims delegation, and Medicare claims repricing tools.
• Advanced organizational skills and ability to manage multiple projects, work under pressure with tight deadlines, be self-directed and work independently.
• Strong analytics and operational problem solving skills.
Job Duties
• Handles Medicare Advantage claims delegation and oversight function.
• Serves as a trainer and staff resource for claims, technical and program issues.
• Collaborates with Provider Services, Provider Relations, Claims and Configuration to reduce the impact of payment errors, implement process improvements and increase Provider satisfaction.
• Oversees delegated activities, including claims payment processes and regulatory compliance.
• Oversees internal controls activities, including routine and ad hoc reviews to identify and mitigate payment risks and financial errors.
• Performs reviews of claims, both pre and post processing.
• Works with delegated vendor to identify, trouble shoot and resolve claims issues.
• Completes claims reviews within established timeframes using Medicare Advantage claims guidelines and proactively informing management of potential underperformance in timeliness and quality.
• Develops reporting tools to communicate review outcomes to OHP team members along with Policy and Procedure development.
• Performs other related duties as assigned.
The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Job Contact:
Donna Jennings
6784589830
Time:
Full time
Salary:
Salary
Category:
Operations
1450 Poydras Street
New Orleans, LA 70112
6784589830
https://www.ochsnerhealthplan.com/