This position is responsible for managing retrospective claims review, management of claims edits , and proactively and retroactively reviewing systems and claims for accuracy and efficiency. This position will manage claims and invoicing and assist in the oversight of our claims processing subcontractor. Participation on multi-disciplinary teams.
Education & Experience
• Bachelor’s degree in Business, Health Care Administration or related work experience• 5 years’ experience with health care claims processing and systems• 5+ years of Supervisory experience
• Claims coding knowledge• Skill with data queries
• Manage Claim Reviewers to resolve claims issues related to authorizations issues, provider issues, pricing and invoicing within standards of accuracy and timeliness. • Recommend audit processes.• Provide reporting, analysis and action plans to management.• Provide training to Claims Reviewers.• Work with the claims subcontractor on Claims and Customer Service issues. • Work with the claims subcontractor on system enhancement design• Work with Field Liaisons to resolve claims issues for Veterans and the Government• Recommends, reviews and modifies all necessary policies, procedures within the department. • Assist in the system integration work between TriWest, claim processing subcontractor and Government systems. • Management of proactive and retroactive claims reviews that are done on a continual basis to ensure claims accuracy and to identify system issues, or processing issues. • Work with Finance and VA on invoice resolution• Management of claim recoupment efforts when necessary.• Perform other duties as assigned.• Regular and reliable attendance is required.