Claims Manager

JOB TITLE: Claims Manager

DEPARTMENT: Claims

REPORTS TO: Claims Director

JOB SUMMARY: Manage and oversee the Claims Department and assigned Claims staff to provide leadership with directions to ensure services are delivered accurately, timely and in accordance with contractual and regulatory requirements to client(s). Act as the primary liaison/consultant between client, health plans, regulatory agencies and Imperial Health teams, primarily system configuration and reporting, with regards to claims processing performance, accuracy, root cause analysis, systemic issues and failures as well as audits and corrective action plans. Participate in client on-site meetings as well as with internal and external operational teams, vendors, and necessary business associates.

ESSENTIAL JOB FUNCTIONS:

• Develops and maintains documentation, including policies, procedures, workflows, and training materials related to claims operations and encounter data submission.
• Ensure that claims payment system data, such as fee schedules and provider billing information, are accurately maintained and up to date.
• Tracks and reports daily claims inventory and productivity, compiling monthly or annual reports for leadership.
• Prepares and maintains reports on claims payment timeliness, inventory, production, high-dollar claims, errors/suspense, denials, and overall departmental performance.
• Oversee pending claims and monitor compliance with claims payment standards.
• Manages provider disputes, refunds, and system errors, conducting root-cause analyses and implementing corrective actions.
• Develops and implements a claims audit program to ensure accurate and timely claims payment in compliance with authorization and regulatory guidelines.
• Leads internal and external audits conducted by compliance departments, health plans, and regulatory agencies, drafting and executing corrective action plans as needed.
• Monitors electronic claims (EDI) processing to ensure timely and compliant claims handling.
• Oversees encounter data collection and collaborates with other departments to enhance accuracy and turnaround time.
• Works with the Finance Department on check-run processing and Explanation of Benefits (EOB) preparation.
• Trains and mentors claim staff, ensuring adherence to company policies, procedures, and regulatory standards.
• Delegates tasks effectively, ensuring staff complete assignments in compliance with departmental and organizational standards.
• Collaborates with the Member Services Department to address member and provider inquiries efficiently.
• Maintains open communication with other departments to achieve organizational goals.
• Continuously improves claims compliance, quality control, and reporting processes.
• Performs additional responsibilities as assigned.
• Maintains consistent attendance and compliance with HIPAA and company regulations.

MARGINAL JOB FUNCTIONS:

• Participate in special projects as needed.
• Performs other duties as assigned.

EDUCATION/EXPERIENCE:

• High school diploma or equivalent required; bachelor’s degree preferred.
• Minimum of five (5) years of experience in IPA, health plan, or hospital claims processing.
• Experience with EZ-CAP software required.
• Preferred experience with Crystal Reports, Virtual Examiner, and SymKey.
• Strong ability to adjudicate claims accurately using pricing tools, fee schedules, and contract terms.

SKILLS/KNOWLEDGE/ABILITY:

• Knowledge of Health Plan Claims Operations, Managed Care and Risk Bearing Organizations
• Effective in influencing and negotiating - builds relationships and respect across functions and at all levels to gain support
• Knowledge of industry regulations, laws, policies, and regulations related to claims processing including CPT and ICD-10 guidelines
• Knowledge of EZ-Cap claims processing workflows, steps, auto-adjudication rules is necessary
• Advanced analytical skills demonstrated through the successful performance of numerous special analytical projects