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Claims Manager (TPA)

The Claims Manager for Care N’ Care will be responsible for managing the oversight of the performance of the claims TPA. This position is responsible for monitoring the accuracy and timeliness of claims processing.

I. Principal Responsibilities

• Review and monitor claims inventories;
• Develop policies and procedures for claims monitoring;
• Develop systems to detect and monitor the accuracy of the adjudication of benefits;
• Develop systems to detect and monitor the timeliness of claims processing;
• Develop systems to detect and monitor denied claims for accuracy, proper notification and timeliness according to CMS standards;
• Work with leadership to move claims operations to a new TPA;
• Participate in monthly compliance audits;
• Insure compliance with CMS standards;
• Insure compliance with State and Federal regulations;
• Provide leadership and guidance to claims staff;
• Organize tasks, time, resources and people.
• Identify and highlight potential risks;
• Participate in all meetings as directed by the CEO.
• Build strong relationship with the external and internal teams to allow for cohesive working relationships.
• Interact with the Centers for Medicare and Medicaid (CMS) to participate in CMS program audits.
• Perform clerical duties as required.

II. Position Requirements

• Minimum 3 years successful supervisory experience;
• Strong Independent decision making and problem solving;
• Excellent interpersonal communication and organizational skills;
• Knowledge of Medicare Claims processing guidelines.
• Previous experience in processing government claims;
• Familiarity with claims workflows, coding and payment policies;
• Ability to work well on a team;
• Proficient with Microsoft Office (Excel, Word, PowerPoint);
• Ability to use multi-line phone system;
• Prefer QNXT/Facets experience;
• Attention to detail and mental concentration are necessary for accurately performing tasks and tolerating interruptions, balancing several ongoing tasks and working in a fast paced environment.

III. Education Requirements:

• High School Diploma required.
• College degree preferred.

IV. Physical Requirements:

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands:
• Must be able to frequently sit, use finger dexterity, has good vision, hearing, and speaking to promote information exchange.
• Must be able to stand and use a copier, collate, staple, and bind large packets for meetings.
• Occasionally may have to lift boxes of office supplies and stack reams of paper on high shelves.
Mental Demands:
• Must be able to frequently problem solve, make decisions, interpret data, organize and analyze work flow, write, plan, and use simple arithmetic.
Working Conditions:
• Work is conducted indoors.
• Requires sitting at a desk in an office settings.
Major activities of the job include:
• Must be able to operate general office equipment including but not limited to: computer, phones, and related media and information devices.
Communication requirement:
• Must have the ability to communicate in writing, speaking, and hearing, both in person and/or by telephone.

The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.

Time:  Full time
Salary:  Salary
Category:  Operations

Updated: 8/16/2018 12:54:17 PM