AIG Business Solution - Manager - Claim Adjudication

JOB DESCRIPTION - Manager-Claim Adjudication

The Claims Manager is responsible for the operational performance of the Claims Department for all lines of business including oversight, development, implementation and on-going development and management of the staff, systems, policies, procedures and day to day operations in order to ensure plan and regulator performance standards are achieved and focus on continuous improvement is maintained. The Claims Manager is a hands-on position and serves as a key participant in the analysis, development, and implementation of regulatory changes, claims initiatives, system implementations, and strategies to achieve department and organization goals. The Claims Manager manages and oversees all regulatory audits. This position hires the best people for roles, reviews annual performance evaluations, and manages staffing effectively and within budget while exhibiting a continual focus on staff development.

QUALIFICATIONS:

- Bachelor's degree or equivalent relevant experience in health care or a related business discipline is required

- 7-10 years claims department management experience with a minimum of 1 year experience in a call centre environment.

- Knowledge of Medicaid and Medicare program strongly preferred and commercial claims experience also a plus

- Demonstrated ability to successfully plan, organize and manage projects

- Demonstrated ability to prioritize and handle multiple tasks while maintaining flexibility

- Sound decision-making, planning, and problem solving skills, with the ability to react quickly and calmly to fluctuations and changes

- Excellent written and oral communication skills and ability to interact with all levels of the organization

- Detail oriented, strong proof reading and editing skills

- Proven ability to recruit, train, coach and develop staff

- Strong computer proficiency in Microsoft applications - especially Excel and Word

- Excellent interpersonal and collaboration skills, positive attitude and proven process improvement skills

- Experience in regulatory audit preparation including oversight, reporting, corrective action

- Must have demonstrated successful ability to translate strategic initiatives into tactical actions resulting in positive outcomes

- Ability to work in cross-functional teams

- Exhibits flexibility in work hours

- Knowledge of medical terminology, ICD-9, CPT codes, pricing, and provider contracts

- Knowledge of all claims processing types (i.e. Facility, Professional, Pharmacy, Dental)

- Experience in interviewing, hiring, and termination of employees

- High degree of confidentiality and professionalism

- Leads by example

ESSENTIAL DUTIES AND RESPONSIBILITIES:

- Maintains monthly compliance with plan and regulator service level standards

- Responsible for hiring and developing a strong high performing team, overseeing and providing on-going coaching, mentoring, and skill development opportunities for each member of the team

- Actively leads efforts to reduce rework, including resubmissions, adjustments, appeals & claim disputes and encounter reversals through root cause analysis

- Assists other departments to achieve company goals and objectives

- Communicates closely with the Claims Team and Claims Director on new, reoccurring challenges and recommendations for improvements

- Manages department to exceed leadership expectations

- Oversees department workflow procedures

- Actively participates in expense reduction efforts (identification, analysis and execution)

- Leads the development and continual refinement of policies and procedures, processes, workflows, etc. to achieve on-going improvements in service delivery, member and provider satisfaction, quality and consistency of customer interactions across product lines

- Exhibits excellent knowledge of all products administered by the plan, in particular coverage and benefits, and claims adjudication

- Actively participates in cross-functional meetings, participating in office efforts and planning to implement changes, review system set up, and exceed overall efficiency and service objectives

- Develops and maintains current and detailed knowledge of key plans systems, the plan's customer service and call tracking system, and all other systems used in daily operations

- Responsible for managing and deploying staff based on department needs including development of schedules based on job duties

- Develops, implements, and monitors on-going reporting mechanisms to oversee department activities

- Produces reports and other data as requested, and oversees special projects. Ensures work is completed accurately and within required timeframes

- Oversees outgoing written correspondence and other written claims related materials produced by other departments. Ensures outgoing material is accurate, reader-friendly, free of errors and professional

- Reviews and proofreads employee evaluations, outlining realistic employee development plans

- Provides timely and well documented employee evaluations to direct reports

- Oversees and prepares materials for regulatory audits

- Oversee Claim Liaisons to work with providers on appropriate claim submission and payment resolution issues

- Successfully manages time in order to balance competing priorities in an ever changing environment in order to continue to move forward on department goals and initiatives

- Effectively delegates and follows through on completion of assignments

- Maintains a high degree of professionalism, consistency, and a positive demeanour at all times

- Works closely with other departments to assure a smooth coordination of efforts and resources

- Completes other projects and duties as assigned

DEMONSTRATES EFFECTIVE MANAGEMENT SKILLS:

- Hires and retains the best people

- Ensures continual personnel development

- Oversees staff work distribution and establishes work standards to promote efficiency and productivity

- Holds regular department team meetings and 1:1 meetings with direct reports

- Motivates and manages staff to ensure performance standards are exceeded

- Gives timely and constructive feedback on performance; documents all corrective counseling.

- Prepares and conducts fair and objective performance appraisal within the month of the employee's anniversary date

- Keeps team apprised of changes in organization and departmental policies

- Acts as a role model in demonstrating the customer service standards of the organization

- Recognizes and analyses the implications of new situations and develops workable solutions to maintain productivity and morale.

CORPORATE INTEGRITY:

- Understands and abides by all departmental policies and procedures as well as the organization's Corporate Integrity Program.

- Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.

- Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.

- Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

- Represents the organization in a positive and professional manner.

- Maintains organizational confidentiality at all times.

- Complies with all organizational policies regarding ethical and compliant business practices.

- Appearance is professional and exemplary at all times