JOB DESCRIPTION: The Claims Manager is responsible for the oversight of internal processes as they relate to claims adjudication. This includes the compilation and scrubbing of claims data in order to analyze, track, and trend various aspects of the adjudicated claims. This includes but is not limited to TAT compliance, production, error rate, midmonth reports for forecasting, health plan monthly reporting, and audits. The Claim Manager will identify root causes of claims payment errors and report to management as well as collaborate with other departments and/or providers resulting in successful resolution of claims related issues.

Knowledge/Skills/Abilities
Develop claims monitoring program

Company Overview:

Full Circle Health Network is an integrated network of nonprofit, nationally accredited providers delivering coordinated, community-based services to vulnerable children, individuals and families across California.

Full Circle exists to ensure more Californians can access culturally congruent and trauma-informed care from a high-quality network of community-based organizations that address their whole-person and whole-family needs.

We accomplish this primarily through the following core activities:

• Serve as a single contracting vehicle for community-based providersto enroll in Medi-Cal managed care plan networks.
• Reduce administrative burden for providers so they can focus on serving clients.
• Drive improved coordination between providers across multiple systems through technology infrastructure, training, and administrative practice support.

The Full Circle Health Network embraces the population health vision of CalAIM. Healing trauma, stabilizing home environments, and reuniting families promotes wellness throughout a child’s lifetime reaping innumerable future individual and societal benefits.

Full Circle Health Network is closely affiliated with the CA Alliance of Child and Family Services, under the governance of the California Alliance Board of Directors. The Network has an advisory board made up of subject matter experts and participants of the network.

• Coordinates, conducts, and claims monitoring as necessary to comply with state, federal, NCQA, and any other applicable requirements.
• Participates in routine Committee meetings, including presenting and leading discussion on audit and monitoring results, proposing solutions to improve network compliance and implementing actions by committee.
• Prepares document evidence for all claims processes and procedures.
• Designs and implements strategies to reduce member grievances and provider dispute overturns.
• Designs and implements program to build/improve positive relationship with providers and payors.
• Designs and implements strategies to increase compliance and quality initiatives.
• Provides or coordinates technical assistance as needed to ensure compliance with all requirements.

Job Qualifications

Required Education

Bachelor's Degree in related field or equivalent experience.

Required Experience

3-5 years management experience in Claims and/or Delegation Oversight.

Must be knowledgeable of Medi-Cal regulations.

Must have an understanding of CMS-1500 and UB-04 forms and be able to read and interpret DOFRs and Contracts.

Must be familiar with EDI file formats- 837, 835, and 277

Experience working with Clearinghouses (i.e. OfficeAlly, ChangeHealth, etc.)

Experience using Power BI

EXPECTED HOURS: This is a full-time position.

Job Type: Full-time

Pay: $80,000.00 - $90,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Weekends as needed

Work setting:

• Remote

Location:

• California (Preferred)

Work Location: Remote