Under the supervision of the Claims Department Manager, this position is responsible for balancing workloads, assisting with establishment of structure and standardization, creation and updating of departmental policies and process and implementation and maintenance of oversight within the Claims Department. Monitoring of claim processing production and quality are required. Improvement initiatives in increasing claims auto adjudication will be performed. Additional functions of this role are supervising overall claim inventory, resolving escalated claim issues and assisting Claims Examiners with policy, regulatory or contractual questions and concerns. This position also will assist in audit related decision making and in training new Claims Examiners on job-specific roles and responsibilities.
Assists in training new Claims Examiners on job specific roles and responsibilities
Meet and/ or exceed claims processing production requirements
Maintain statistical accuracy of 97%, and financial accuracy of 98%
Correct DoD error report as needed
Provide excellent customer service to internal and external customers
Other duties as assigned by management
Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate completion of tasks/goals
Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
Analytic ability to organize and prioritize work to meet deadlines
Ability to organize and prioritize work to meet deadlines
Strong computer application skills including Microsoft Word, Excel and Visio
Excellent written and verbal communication skills required
Good judgment, initiative and problem solving abilities
Ability to handle and resolve complex issues independently
Knowledge of Medicaid, Medicare Advantage, Tricare and Health Care Exchange programs preferred
Knowledge of claims processing, system configuration, edits, adjustment adjudication and claim department processes
Knowledge of CPT/HCPCS, ICD-10 coding and medical terminology.
Ability to learn new policies and processes based on written material and observation
Ability to establish and maintain professional, positive and effective work relationships
2 years Healthcare experience with Managed Care experience required
Prior Claim Team Management experience preferred
Three years claims processing experience required with Managed Care experience preferred
Claim system configuration experience preferred
Prior experience working with TRICARE, Texas Medicaid, Medicare Advantage highly desirable.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.