Job Summary:Direct overall planning, development, and operations of the claims management system. Provide recommendations to executive leadership team and implement plans regarding the claims management system.
Essential Functions: - Provide strategic input on claims processing and payment decisions within the Claims Management (CM) Department.
- Participate in the development of the CM budget.
- Schedule and supervise internal and external audits related to claims issues and develop reports on audit findings and recommendations.
- Manage day-to-day workflow and operations of claims management.
- Establish policies and procedures for claims processing, including standards of performance, claims auditing, and other measurement techniques.
- Supervise department employees, including hiring and performance management.
- Review settled claims to ensure compliance with organizational practices and procedures.
- Verify and analyze data used in setting claims to ensure accuracy and compliance with procedures.
- Report on overpayments, underpayments, and irregularities.
- Consult with legal counsel on claims requiring litigation.
- Ensure compliance with CPT and ICD requirements.
- Analyze account details and respond to inquiries regarding claims payment or status.
- Assist with pre-claim system edits and provide guidance on coding issues.
- Support medical and behavioral health providers with coding and billing documentation.
- Participate in encounter reporting and ensure accurate coding for various programs.
- Review billing encounter forms annually to update codes.
- Provide ongoing orientation to new employees and clinical providers on coding, billing documentation, and compliance.
- Review provider medical record documentation and employee performance to monitor compliance with coding and billing regulations.
- Implement compliance plans for coding and billing accuracy and identify risk areas for correction.
- Assist with educational programs for providers and staff, including responses to provider inquiries.
- Participate in various committees and meetings as necessary, including the OCHN Compliance Committee.
- Chair the OCHN Procedure Code Workgroup.
- Maintain current industry knowledge and attend conferences for professional certifications.
- Ensure compliance with OCHN's Health and Safety Policies.
- Oversee the administration, configuration, and maintenance of the claims adjudication system.
- Direct review and implementation of business process changes impacting the claims system.
- Establish partnerships with the Senior Leadership Team to ensure claims system accuracy.
- Lead compliance audits and remediate identified issues.
- Perform any other related duties as assigned.
Job Requirements and QualificationsEducation:
- A bachelor's degree in business administration or a related field.
- Master degree in a relevant discipline preferred.
Training Requirements (licenses, programs, or certificates):
- Must have RHIT or CPC certification.
- Note: If the selected employee does not have this certification, that employee must receive the certification within six (6) months of the date of hire to maintain employment.
Experience Requirements:
- Minimum of five (5) years managerial/supervisory experience with at least five (5) years of professional experience in outpatient, Medicare and Medicaid, computerized and manual billing for third party payors.
Job Specific Competencies/Skills:
- Demonstrated effective interpersonal skills.
- Demonstrated ability to work effectively in a team environment.
- Demonstrated effective negotiation skills.
- Demonstrated effective written and oral communication skills.
- Demonstrated effective computer skills.
- Demonstrated effective project management skills.
Managerial Competencies/Skills
- Ability to recognize and analyze complex operational/administrative or fiscal problems, and to recommend and implement solutions.
- Ability to work collaboratively and create a team environment that resolves problems and implements solutions in an environment that fosters system -wide continuous improvement.
- Ability to recruit, select, supervise, plan, direct, and evaluate the work of professional, administrative, and clerical employees.
- Ability to provide developmental opportunities for future succession planning and skill enhancement.
- Ability to communicate effectively, both orally and in writing.
- Ability to conduct effective meetings.
- Ability to initiate, plan, develop, coordinate and implement system wide programs.
- Highly effective project management skills.
- Highly effective interpersonal, active listening, negotiation, and conflict resolution skills.
- Ability to respond appropriately to and manage crisis situations.
Knowledge Requirements:
- Knowledge of Claims Management.
- Knowledge of the Billing Process including knowledge of computerized billing, electronic claims submissions, and outpatient billing procedures for third party carriers.
- Knowledge of coding CPT4 and ICD-9 and ICD-10.
- Knowledge of medical terminology and medical procedures as related to physician Medicaid, Medicare, and clinical support billing codes.
Oakland Community Health Network's Core Competencies:
- Interacting with others in a way that gives them confidence in one's intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust)
- Making customers and their needs a primary focus of one's actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus)
- Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning)
- Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)
- Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)
Additional Information(Travel required, physical requirements, etc.):
- Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.
- Must be available for meetings and events which may occur outside of standard office hours.
- Work performed primarily in an office environment.
- Hybrid (onsite/remote) work schedule available.
- The ideal candidate must be able to complete all the physical requirements of the job with or without a reasonable accommodation.
