ABOUT THE ROLE:

The Manager of Claims Operations/Payment Integrity will play a key role in achieving the highest-level of claims excellence through creation and implementation of consistent business processes aligning with strategic goals of the XO Health Operations Department. The Manager of Claims Operations/Payment Integrity will work closely with the SVP of Operations and Payment Integrity and other departments to develop, communicate, implement, execute, and measure claim business processes.

RESPONSIBILITIES:

• Direct day-to-day operations of claims processing department to ensure that claims are processed within statutory and company guidelines.
• Ensure procedural and financial claims metrics and service level agreements are met.
• Involved in detecting and correcting claim-based factors such as errors, coding guidelines, fraud, waste, abuse.
• Collaborate with leadership from cross functional departments to ensure efficiency and proper prioritization of the claims adjudication process.
• Provide regular feedback regarding claim processing performance in critical areas such as compliance policy, process and procedure adherence, and customer satisfaction.
• Implement and lead operational improvement efforts that produce successful results in the aforementioned areas.
• Coordinate with the Claims Vendor Manager and assist with the development, aggregation, and communication of vendor KPI's and performance.
• Assist in the development of claims best practices, including but not limited to, claim processing guidelines, policies and procedures, job aids, and claims bulletins.
• Act as a liaison with other departments to obtain and analyze information to further improve claims handling practices and customer relationships.
• Monitors performance, reviews open and closed claims to ensure that claims have been properly handled and moved towards resolution in a timely manner.
• Supports training of claims examiners, claims managers, and senior claims leadership.
• Acts as an SME resource regarding coverage issues, reserves, exposure, settlement value, and strategy.
• Submits weekly management reports and prepares special reports when requested.
• Responds to inquiries from various other departments with reaction to claim handling, processing, and coverage issues.
• Assists in the conducting of audits of vendors, both primary and independent.
• Available in an emergency 24/7 and extended hours as needed.
• Work with quality assurance personnel and assist as needed.
• Assists senior management with other projects and initiatives as requested.
• Travel if needed to support train-the-trainer sessions for operational claim staff.
• Travel for participation in business management meetings, and support of other business initiatives.

EXPERIENCE REQUIRED:

The qualified candidate will have:

• 5 years of proven medical claims operations leadership experience. Bachelor’s degree in healthcare administration or equivalent relevant work required.
• Strong knowledge of medical terminology, health insurance plans, medical billing concepts.
• In-depth understanding of Facility, Facility Stoploss, DME, Behavioral Health, Coordination of Benefits claims processing.
• Excellent written and oral communication skills.
• Excellent customer service and follow-up skills.
• Strong organizational leadership skills and detailed oriented.
• The ability to manage multiple projects at one time.
• Analytical, strategic minded and goal oriented.
• A leader with the ability to work independently.
• Strong attention to detail.