Manager of Claims

As the Manager of Claims at Avesis you will help create communities and systems of care that supports everyone having access to quality healthcare and services while being treated with dignity. With over 40 years' experience managing commercial and government-sponsored benefit programs, we are one of the leading vision and dental insurance services companies in the nation, with an extensive network of providers. We provide essential vision, dental benefits to small and large businesses, municipalities, government agencies, and major medical providers and ensure members receive necessary dental and vision services to support overall health.

The Claims operations team at Avesis is responsible for timely and accurately processing all claims. This is the team's continual commitment to ensure provider payments are accurate and member benefits are maximized. We have a proven track record for processing clean claims within 30 calendar days or less, reducing provider abrasion and increasing member satisfaction.

Job Summary:

The Manager of Claims is responsible for direct oversight of Claims Supervisors, processing staff and claims technology initiatives. The Manager is responsible for upholding and administering all claims processing functions and will participate and lead in the development and performance of the Claims Processing team and ensuring high quality and timely outcomes. This includes work-flow oversight, assessment of error reduction initiatives, consistent execution of claim payment procedures, completion of special projects, overseeing supervisor team performance. This individual will present relevant data, analysis and solutions related to feedback regarding identified processing trends, process improvement opportunities, general areas of concern found in routine review activity, claims processing turnaround times and quality benchmarks to the claims Executive Leadership Team.

Functional:

• Ensure direct oversight of Claims Supervisors and claims support staff, claims processing workflows, queue management and daily transactional operations and completion and delivery of annual performance reviews.
• Demonstrate knowledge and understand contracts and performance requirements, claims processing workflow, automated process implantation and payment process.

• Oversight of timely and accurate processing of claims as required by contractual and regulated time frames.

• Interview, select and hire applicants for various Claims department positions.

• Manage employee performance, set goals, oversee workloads, monitor productivity/metrics and quality.

• Monitor claims inventory and assist claims supervisors to proactively address areas of concern.

• Assist in monitoring, planning, and assigning employee job requirements.

• Development of specific goals and objectives for supervised team members.

• Ensure quality and productivity standards are being monitored and feedback is being provided to frontline staff.

• Assist management and processors in resolving aged claims or handling of claims adjustment projects.

• Presenting topics and attendance in team meetings related to claims processing reviews and updates for company policies and procedures, audit findings, and other related communications.

• Identify opportunities to develop and oversee implementation of improvement plans for best operations and outcomes.
• Support audit activity including both internal and external audit activity when needed.
• Participate in annual review and maintenance of departmental workflow, Standard operating procedures, and employee performance review activity.
• Communicate timely with internal Avesis stakeholders regarding pending or open deliverables.
• Perform other duties occasionally as assigned.

Core:

• Exposure/experience to CPT, HCPC, Dental and diagnosis coding.
• Knowledge of general claims processing principles.

• Ability to pivot between competing priorities and execute responsibilities within tight deadlines.

• Strong attention to detail and accuracy.

• Strong organizational skills with the ability to manage multiple tasks and meet deadlines.

• Strong communication skills, both verbal and written.

Behavioral:

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.
• Initiative: readiness to lead or take action to achieve goals.

• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.

• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.

• Detail-oriented and thorough: managing and completing details of assignments without too much oversight.

• Flexible and responsive: managing new demands, changes, and situations.

• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.

• Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.

• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Minimum Qualifications:

• Bachelor's degree or equivalent combination of education and experience
• Minimum 5 years supervisory or management experience leaving leading a production team.

• Minimum 3+ years' experience leading or participating in the development of claim enhancements, including auto-adjudication triggers; robotic process automation and claims adjudication system logic.

• Knowledge of Medicare, Medicaid, and/or Commercial insurance terminology and high-level clams' payment processes.

• Advanced in Microsoft Office products, including Excel, Word, Adobe, and other Windows-based tools used to aggregate, analyze, trend and report recommendations for increased operational performance.

• Ability to work flexible hours to accommodate business needs in all time zones.

• Excellent listening, communication (verbal and written).

As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• Master's degree in a related field, will consider experience in lieu of degree.
• Experience within Dental/Vision insurance or healthcare organizations.

At Avēsis, we strive to design equitable, and competitive compensation programs. Base pay within the range is ultimately determined by a candidate's skills, expertise, or experience. In the United States, we have three geographic pay zones. For this role, our current pay ranges for new hires in each zone are:

Zone A: $74,260.00-$123,760.00Zone B: $80,940.00-$134,900.00Zone C: $87,150.00-$145,250.00FLSA Status: Salary/Exempt

This role may also be eligible for benefits, bonuses, and commission.

Please visit Avesis Pay Zones for more information on which locations are included in each of our geographic pay zones. However, please confirm the zone for your specific location with your recruiter.

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
• Life and disability insurance.
• A great 401(k) with company match.
• Tuition assistance, paid parental leave and backup family care.
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
• Employee Resource Groups that advocate for inclusion and diversity in all that we do.
• Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

How To Stay Safe

Avēsis is aware of fraudulent activity by individuals falsely representing themselves as Avēsis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.

Avēsis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avēsis recruiters will come from a verified email address ending in @ Avēsiscom.

We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to [redacted].

To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avēsis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.