The Manager, Claims Administration oversees all activities related to claims processing including establishing performance standards, training, departmental policies and procedures, auditing and other performance measurement techniques to ensure the achievement of stated department and Health Plan goals and objectives. The Manager, Claims Administration participates in the development of interdepartmental policies and procedures relating to claims payment. Through auditing and internal reporting, this position proactively identifies trends and develops recommendations for change. Additionally, this position supports our health plan administration department with identifying areas for improvement as it relates to benefit structure and plan administration.
- Develops processes and procedures which will result in an efficient and accurate claims processing.
- Assists in theresearch and development of policy and payment rules to ensure that we are in compliance with our lines of business..
- Collaborates with all health plandepartments to ensure that our claims processing function meets our performance standards for efficiency, timeliness, and accuracy thereby contributing to employee, provider and member satisfaction.
- Establishes and maintains a claimsaudit function which results in increased accuracy rates by processor and for the department overall, thereby increasing employee, provider and member satisfaction as well as controlling financialliability.
- Collaborates with the IT Department to ensure the transaction system provides accurate claims adjudication for accurate financial analysis.
- Analyzes and trends claims data which results in the identification of changes which will improve performance of claims processing function (e.g. staffing levels, system enhancements, workflow changes, implementation of automated claim review functions, etc.).
- Assumes project oversight which supportsstrategic initiatives. Effectively sets goals and monitors performance of all team members.
- Supports employee development through meaningful development conversations and IDPsupport.
- Demonstrates an understanding of and alignment with Martin’s Point Values.
- Knowledge of regulations relating to managed care claims processing and related functions.
- Knowledge of managed care computer systems, features, and reporting.
- Knowledgeable about employment practices, budgeting, and general management functions.
- Demonstrated interpersonal, communications, operational, team building, and quality improvement skills.
- Demonstrated effectiveness and skill in the use of automated claims processing technology in a manner which maximizes process efficiency.
- Thorough familiarity with medical and hospital service technology, coding, and legitimate billing practices, and use of automated claimsediting technology.
Record of accomplishment in project management and change management.
- Effective team leader and builder
- Mentor and coach
- Ability to design work processes around customer needs and expectations
- Ability to establish accountability