The Claims Manager has primary responsibility for oversight/compliance of the claims processing, audit functions, claims adjustment projects, and Health Plan demands for all business/vendor segments.
Under the direction and support of the Executive Director of Operations, the Claims Compliance Manager develops and initiates systems, policies and procedures for claims processing, audits and/or related activities/engagements of the revenue system management.
The Claims Manager acts as liaison between SHP and regulators for all claims related activities that include but not limited to DMHC audits, CMS audits, Health Plan reporting and delegation audits. Responsible for maintaining claims policies and procedures and insuring that they are current and reflect the workflow process of SHP. The position provides training, guidance and oversight to the Claims staff to ensure the department meets the company’s strategic goals.
Minimum 3 years supervisory experience or demonstrated leadership ability required
Comprehensive knowledge of Medicare, ODAG, and Part C reporting requirements
Working knowledge of Claims Information Systems
Comprehensive knowledge of CPT, ICD-10, inpatient procedure coding, HCPCS Revenue Codes, medical terminology, and COB required
Microsoft Excel, Work, and Access skills
Detail oriented with excellent verbal and written communication skills
Demonstrates effective communication, interpersonal, and organization skills
Ability to plan and identify opportunities to effectively utilize resources
Excellent critical thinking skills
Bachelor’s degree in Business, Health Care Administration or related field or equivalent experience required.