The Claims Manager is responsible for the daily management of the Medical Claims Processing team members. This position demonstrates high levels of expertise in the department's operations; provides training and staff development; performs administrative duties and support to deliver high levels of service, quality and production. This position should have a comprehensive understanding of the Plan Documents/Guidelines under their scope of responsibility.

Essential Job Duties:
• Maintain HIPAA/PII guidelines to ensure the confidentiality of all calls and documents
• Administrative

o Serve as a liaison between departments, vendors and clients to ensure collaborative progress

? Exhibit strong working knowledge of customer business operations

o Demonstrate strategic business acumen in decisions affecting bottom line focus

o Generate and deliver accurate and timely reports

o Assist with troubleshooting for technical issues
• Customer Service

o Serve as a role model in demonstrating core values of customer service

o Encourage continuous learning, personal development and accountability through team members

o Provide timely and thorough responses to internal and external customers

? Respond to member and group correspondences regarding plan/guideline or claim questions within 24 hours

o Escalate difficult issues to the appropriate channels

o Assist in the processing and resolution of escalated issues
• Quality Assurance

o Ensure team compliance with service standards

o Follow trends within assigned scope and alert appropriate parties of any trends that fall outside quality parameters

o Develop and execute plans to meet established goals

o Provide continuous feedback to strengthen and optimize quality performance

o Work cross-departmentally to improve or streamline procedures

o Maintain up to date knowledge on industry trends and look for new data sources

o Develop new and improve current internal processes to improve overall quality
• Special projects as assigned

Management Responsibilities:
• Conduct regular performance evaluations of employees and provide ongoing feedback and coaching as necessary
• Address and counsel employees on behavioral or performance problems and implement corrective action as necessary
• Explain and administer company policies required for team members to perform duties successfully
• Distribute and monitor departmental workloads to ensure adequate coverage while meeting quality and service levels
• Oversee new and ongoing training and update training manuals
• Coordinate and actively participate in departmental meetings

Skills/Abilities:
• Excellent verbal and written communication skills with high attention to detail
• Excellent customer service skills
• Strong analytical and problem-solving skills
• Confident decision-making abilities
• Demonstrated ability to work independently, prioritize workloads and manage priorities to meet deadlines

Requirements

Education/Experience:
• College degree or equivalent required
• Degree in Medical Billing and Coding or related field preferred
• Knowledge of medical terminology preferred
• 7 -10 years Claims Examiner experience or equivalent required
• 4 -7 years management experience required

Physical Requirements:
• Indoor office environment with moderate noise
• Intermittent physical effort may include lifting as much as 25 lbs., walking, stopping, kneeling, crouching or crawling may be required
• Frequent sitting, use of a keyboard, reaching with hands and arms, talking and hearing approximately 70% of the time; 30% or less time is spent standing
• Normal vision abilities required including close vision and ability to adjust focus