Job PurposeThe Claims Manager is responsible for overseeing and directing delegated Managed Care Claims adjudication and manage our medical claims department.In addition, you will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values. Culture and Values ExpectationsAt HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission “to deliver quality and compassionate care with outstanding service, every patient, every time”. As a Claims Manager at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.

• Integrity: Do the right thing, the right way, every time.
• Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.
• Compassion: Treat everyone with respect and dignity.
• Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.
• Synergy: Collaborate to improve outcomes.
• Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.
• Stewardship: Use resources responsibly and efficiently.
• Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.

Essential Job Duties & Responsibilities

• Participate in inter-departmental business activities, including input into budget preparation
• Prepare inbound and outbound 835, 837, EFT, etc.
• Encourage positive staff results by communicating job expectations; planning, monitoring, and appraising results; coaching, counseling, and implementing corrective action plans when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards.
• Complete performance evaluations in a timely manner.
• Create, review, and/or update departmental procedures, workflows, and resource material.
• Implement necessary policy and regulatory changes.
• Develop and manage auditing and quality control standards.
• Supervise the coordination of workflow and staffing of day-to-day activities as well as assigning and monitoring work of staff in order to adhere to productivity and quality standards to meet stated goals.
• Manage delegated claims audit and reporting.
• Ensure CMS and delegated claims compliance.
• Resolve and/or gather appropriate guidance for any escalated issues.
• Other duties, as assigned

Experience

• Minimum 5 years medical claims adjudication working experience, with at least 3 years of managerial experience
• Medicare guidelines and healthcare claims regulation knowledge
• Delegated Medicare Advantage Experience is required
• Experience with claims adjudication software

Education

• Bachelor’s Degree preferred. In lieu of a degree, 6 or more years of relevant experience

Knowledge, Skills & Abilities

• Medicare guidelines and healthcare claims regulation knowledge

Work Hours, Travel Requirements

• Monday – Friday, 8:00 a.m. – 5:00 p.m., and as needed to complete projects.
• Travel to medical offices may be necessary for the purpose of providing benefit education.

Working Conditions & Physical Requirements

• This job operates in an office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, scanners, filing cabinets and fax machines.

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Job Type: Full-time

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person

Work Location: In person