111306 - Claims Manager
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#111306 Claims ManagerInitial Review Date: Mon 10/11/2021
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UCSD Layoff from Career Appointment: Apply by 08/30/21 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.
Special Selection Applicants: Apply by 09/09/21. Eligible Special Selection clients should contact their Disability Counselor for assistance.
This position will remain open until filled.
The Claims Manager is responsible for the overall management, direction and oversight of the PHSO Managed Care Claims Department, ensuring timely and accurate adjudication of claims, delegation audit compliance, and compliance with health plan, CMS and DMHC guidelines. The manager establishes benchmarks and quality control audit programs along with necessary reporting to validate accuracy of claims processing and comply with regulatory data submission requirements. Incumbent serves as a subject matter expert in HMO claims administration, provides guidance and support to the Claims team, facilitates training, and assists in identifying process improvement opportunities to streamline and automate work as needed.
Operations and Delegation Compliance:
- Oversees the interpretation and implementation of regulations and mandates pertinent to HMO claims processing to ensure delegation compliance.
- Implements effective quality control and audit programs along with necessary reporting to validate accuracy of claims processing.
- Works in collaboration with Internal Claims Auditors to develop corrective action plans in response to identified deficiencies; implements corrective actions; and continuously monitors to ensure compliance.
- Identifies error trends, defects and process improvement opportunities.
- Collaborates with management to improve claims operations by identifying application or system issues and recommends and implements innovative solutions.
- Establishes and maintains documentation related to departmental processes and workflows (policies and procedures, reference tools, production reports) to ensure compliance with best practices, production standards, federal and state regulations, and health plan policy and delegation requirements.
Team Support and Management:
- Provides leadership, direction and guidance to the Claims Department staff and establishes metrics to ensure departmental goals and objectives are being met.
- Manages inventory and assignments to balance workloads and resources.
- Supports and leads team members in the identification and implementation of improved processes, increased automation, and improved claims accuracy.
- Assists in validation and testing to ensure claims adjudication system is configured and maintained appropriately to support accurate claims processing and adheres to regulatory requirements.
- Advises staff of all procedural changes in a timely manner, documents and ensures changes are implemented promptly and effectively.
- Oversees claims customer service functions to ensure responses to provider inquiries, disputes, appeals and internal inquiries are resolved accurately, promptly and with a high level of customer service.
- Coaches and develops staff; assists in defining goals and establishes trust.
Collaboration and Communication:
- Provides ongoing communication to team members regarding organizational and operational changes.
- Leads and contributes to various projects representing PHSO Managed Care claims operations, ensuring deliverables are met timely and work is of high quality and integrity.
- Represents claims operations in internal and external meetings, audits and joint operation committee meetings; maintains positive relationships with key customer contacts.
Nine (9) years of related experience, education/training in HMO claims processing and management experience, OR a Bachelor’s degree in related area plus five (5) years of related experience/training in HMO claims processing and management experience.
Management experience directly managing staff, including performance management, employee development and recruiting.
Proven experience with Commercial and Medicare Advantage HMO lines of business required.
Effective analytical and program development skills as well as significant familiarity with managed care systems and processes.
Strong leadership and management skills.
Excellent interpersonal, verbal and written communication skills.
Demonstrated attention to detail and organization.
Proficient computer skills.
Thorough knowledge of HCPCS/CPT and ICD-10 codes.
Must be able to work various hours and locations based on business needs.
Employment is subject to a criminal background check and pre-employment physical.
Job offer is contingent on successful engagement in the UC COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).
UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, and several outpatient clinics. UC San Diego Medical Center in Hillcrest is a designated Level I Trauma Center and has the only Burn Center in the county. We invite you to join our dynamic team!
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