POSITION SUMMARY:

The Claims Manager position is a key part of the department’s successful operation. This position has direct responsibility for all Commercial Claims Operations. The Claims Manager is a senior level member of the organization who will monitor, support, and influence action to improve, when necessary, the day to day productivity of claims operations within the company. The Claims Manager will work with the General Manager to establish the strategic planning of all Claims payment resources for the corporation.

This position reports directly to the General Manager and leads a team of Claims Processors and, Claims Auditor. The Claims Manager interacts with clients, providers, members; team associates and must possess the skill to coordinate work issues within each of the departments that report to them. As a Manager, it is critical to create leadership and be able to develop each team member. The ability to be organized, accurate, efficient, interact and communicate well with others are necessary skills for this position.

This position requires extensive use of LuminX, Outlook, Excel, and Word. Good attendance, positive attitude, acceptable production and operational results are critical to the success of the position. The Claims Manager exercises fiduciary and managerial responsibility over the entire claims area and interfaces with internal resources in a prudent and ethical manner.

The Claims Manager works with the General Manager to empower staff growth and client retention with an accountability to contribute to the overall success and profitability of the organization.

POSITION KEY ACCOUNTABILITIES:

  • Develop and maintain all staff schedules to appropriately service our contract requirements.
  • Assist with hiring all new team members.
  • Assist in completing team member reviews.
  • Coordinates with Plan Builders to test and assure all plans are built to client document specification.
  • Assist in setting production goals. Will regularly monitor results and communicate them to the team members, notifying the General Manager when a team member is not meeting expected results.
  • Processes claims as needed to assist with production goals.
  • Reviews and evaluates all Claims Operations functions and with the Claims Administrator assures uniform and documented processes, and management strategies are in place.
  • Assures short term and long-range planning for all functions of the claims department are performed for the well-being of the corporation and its client base.
  • Oversees and provides counsel to each member of the Claims Team as they make decisions that affect day-to-day operations and make recommendations for changes in strategies, plans, and policies for the unit.
  • Promotes an environment that encourages collaboration and creativity to advance collaborative efforts within each operational unit. Maintains and encourages open communication among the various teams within the organization.
  • Works collaboratively with senior executives, and key personnel in the formulation and implementation of company policies, standardized procedures, and decisions affecting our client base.
  • Holds responsibility for all claim production and assures the company of appropriate quantity and quality.
  • Coordinates all Claims units to assure the most current version and operation of the claims system and other supporting systems are in use for the operations of the organization.
  • Works hand in hand with the IT department.
  • Keeps abreast of all emerging system activities as it relates to our current claims system in order to assure efficiencies in the department and determines the appropriate resources needed to respond to any increased workload.
  • Supports the Sales staff and senior management as needed.
  • Prepares monthly reports which reviews the effectiveness our Claims Unit, as it relates to the production and turnaround of our clients claims, and provides reasonable assurance that operations are cost effective and efficient and client and company assets are safeguarded.
  • Assures all Claims processing procedures meets or exceeds the data security standards set by HIPAA and or our government clients.
  • Manages, reviews, file structure to assure system flows/links are appropriate and working. Creates work flows to document system processes.
  • Assures and maintains the integrity of Claims processing and claims products sold and used for Capitol business.
  • Coordinates all audits for the claims departments and reports results to leadership as needed.
  • Assures all performance guarantees are met and reported on as needed by each client and communicates results internally.
  • Uses the audit function to track training need of all staff related to the claims units.
  • Works with the General Manager and in coordination of the Claims teams, not limited to, but to include, adjustments, prior authorizations, case management, corrections, voids, appeals and stop loss filings.
  • Coordinates with Plan Builders to test and assure all plans are built to client document specification.
  • Develops, maintains and monitors job descriptions as it relates to each unit within the claims department, in coordination with HR.
  • Works with the Technical Services area to support and build the ability to auto adjudicate claims as appropriate to the client.
  • Coordinates and works with all Account Managers, as needed.
  • Monitors and controls all outside vendors, in conjunction with the General Manager, contracted to support claims processing.
  • Determine and plan future needs and strategies as it relates to claim system operations.
  • Manages all Front-End solutions to the Claims system and incoming documents including the mail room and scanning. Reviews and determines policy and procedure for this function and determines the scope of responsibilities whether internal or external.

Attributes and Skills to assure Success:

  • Excellent system use and management abilities
  • Excellent communication, written, telephonic and personal skills
  • Exceptional leadership
  • Ability to manage and follow through consistently and accurate
  • Attention to detail
  • Completion of all responsibilities in a timely manner
  • Independent thinking
  • Organized work habits
  • Company loyalty

Requirements:

  • High School Diploma or general education degree
  • Minimum 5 years team supervision
  • At least 8 years medical claims processing experience inclusive of managing the claims department (inventory and staff), and expert knowledge of relevant ICD codes
  • Proficient use of Microsoft Outlook, Excel, Word
  • LuminX experience, preferred
  • Ability and willingness to commute to onsite office

Supervisory Responsibilities: This job has the full scope of supervisory and management duties.

Lucent Health is an Equal Opportunity Employer.