Claims Manager

Confidential Company  •  Miami, FL

5 - 7 years experience  •  Managed Care & Health Insurance

$100K - $140K
Posted on 02/21/18 by Aubry Woff
Confidential Company
Miami, FL
5 - 7 years experience
Managed Care & Health Insurance
$100K - $140K
Posted on 02/21/18 Aubry Woff

Claims Manager

Reaction Search International is a leading retained global executive search firm. With offices in 42 marketplaces throughout the United States, RSI works with a wide variety of companies, from Fortune 500 down to investment-backed start-ups.

POSITION PROFILE

Our client is a leading company providing group employee health benefit plans, including medical, dental, life, and disability. They have a high-priority need to recruit a Claims Manager to oversee the claims department, ensuring claims are processed in accordance with turnaround times, quality, and production standards. This position reports to the Director of Operations.

Location: Caribbean Islands

Essential Duties and Responsibilities:

Duties & responsibilities include, but are not limited to:

  • Oversee work flow of the Claims Department.
  • Monitor claims and auditing turnaround times to ensure objectives are met.
  • Communicate daily inventory to the Director of Operations.
  • Confirm all industry reference material is updated accordingly.
  • Handle overpayments and follow up requests on a timely basis.
  • Report pended claims exceeding $25K.
  • Communicate staffing issues or concerns to the Director of Operations.
  • Maintain proper employee documentation.
  • Review daily mail log to identify high dollar claims meeting the external medical review criteria and handle accordingly, while notifying proper management.
  • Notifies Overseas Network Provider of claims not returned from re-pricing.
  • Identify and establish processes and procedures to ensure efficiency and consistency throughout the Claims Department.
  • Set goals and objectives for all Claims Department and individual employees.
  • Participate in recruitment process and contribute to decision making process.

Requirements:

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.

  • Bachelor?s degreerequired.
  • Certification or professional qualification in health insurance, or significant progress towards a relevant professional qualification is preferred.
  • 5 -10+ years of medical claims processing experience and knowledge of both U.S. Claims, and an understanding of various fee schedules applicable to the local market.
  • 5 -10+ years at a supervisory level in a medical claims operation.
  • Experience working with U.S. healthcare system and experience of US claims processing, provider and network discounts and negotiating contracts with independent service providers.
  • Thorough understanding of group health benefit plans including medical, dental, life, and disability.
  • Strong knowledge of ICD-9 & ICD-10, CPT, ADA, ODA coding and medical terminology.
  • Superior communications and organizational skills, and a service-oriented approach.
  • Proven ability to negotiate with external and internal clients and work under pressure.

*LOCATION FOR THIS POSITION: In the Caribbean*

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