Sr. Manager, Claims

The Sr. Manager, Claims, manages the claims inventory and provides timely and accurate claims and encounter processing. Responsible for the supervision of the claims staff, including recruiting, hiring, and performance management. They will ensure compliance with all contractual and regulatory agencies for all product lines and governing bodies.

Responsibilities

1. :Directs departmental activities related to claims administration
2. .Maintain knowledge of claims policies and procedures, and ensure performance is in accordance with applicable regulatory requirements
3. .Ensures that areas of accountability are informed of current compliance requirements and that ongoing training is provided
4. .Concentrates resources on improving claims payment accuracy and decreasing processing cost per claim
5. .Identifies potential company risks and implements appropriate courses of action, and develops strategies to reduce adjudication errors
6. .Utilizes standardized processes, tools, methodologies, and presentation templates, including: project timetables, progress/milestone reports, financial reports, resource, and issues tracking
7. .Accountable for all aspects of project management, including: scope planning, scope definition, analysis, activity sequencing, activity duration estimation, schedule development, resource planning, budgeting, project plan development and maintenance, risk management, reporting, implementation, measures development, and project wrap-up
8. .Communicates effectively with all appropriate internal and external individuals, as well as maintains regular contact with the Finance and Claims management and other project sponsors to coordinate project activities and outcomes as appropriate
9. .Identifies potential project risks and implements appropriate courses of action to address project slippage and develop strategies to mitigate future risk. Escalates critical issues for appropriate/timely resolution as needed
10. .Prepares and presents regular project progress and turnaround/inventory reports for Finance management
11. .Also works closely with other members of Finance and Claims management to plan project activities such as, but not limited to, Auto-adjudication, system pricing, and duplicate logic reporting
12. .Develop system requirements and create documentation for internally produced system changes with appropriate sign-off
13. .Responsible for unit and integration testing of all products before implementation in production systems
14. .Responsible for working on special projects such as professionally generated claims analysis
15. .Responsible for the development and testing of auto-adjudication applications
16. .Ability to translate health benefit plan design, claims, and health-related insurance products into systems configuration
17. .Ensures the successful migration of set-ups from the development to the production environment
18. .Provides technical support, training assistance, and expertise to Claims staff or other departments as determined through all phases of the project (e.g., Research, Outcomes, Provider notification of findings)
19. .All other duties as directed by management

.
Education/Experienc

1. e:Bachelor's degree or 3-5 years of experience with claims processing and system configuration, preferably with EZCap or similar systems in the healthcare secto
2. r.Strong collaboration skills with management and project managers to identify business process issues, analyze operational efficiencies, implement creative solutions, and measure outcome
3. s.A disciplined, process-oriented, and data-driven approach is essentia
4. l.Knowledge of claims payment policies is preferre
5. d.Requires excellent organizational, communication, and writing skill
6. s.Ability to work independently with minimal supervision and prioritize tasks effectivel
7. y.Proven capability to conduct and interpret qualitative and quantitative analyses, along with strong problem-solving skill
8. s.Must work well with individuals at all levels of the organization; being an effective team player is crucia
9. l.Demonstrated initiative, independent judgment, and self-starter qualities are necessar
10. y.Proficient in PC-based business software, including the Microsoft Office suite (Access, Excel, PowerPoint, Word

)

.
The pay range for this position at commencement of employment is expected to be between $95,000 - $105,000 annually; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experien

ce.
The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offe

red.
Details of participation in these benefit plans will be provided if an employee receives an offer of employ

ment.
If hired, the employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market fa

ctors.As one of the fastest-growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming, and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our su

ccess.
Full-Time Position Be

nefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work a

nd life.Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid

options.
Health and

• Wellness:Employer-paid comprehensive medical, pharmacy, and dental for
• employeesVision
• insuranceZero co-payments for employed physician offi
• ce visitsFlexible Spending Acco
• unt (FSA)Employer-Paid Life
• InsuranceEmployee Assistance Prog
• ram (EAP)Behavioral Health

ServicesSavings and Re

• tirement:401 (k) Retirement Sav
• ings PlanIncome Protection

InsuranceOther

• Benefits:Vaca
• tion TimeCompany cel
• ebrationsEmployee Assistanc
• e ProgramEmployee Refer
• ral BonusTuition Reim
• bursementLicense Renewal CEU Cost Reimbursemen
• t ProgramBusiness-casual working en
• vironment
• Sick daysPaid
• holida

ysMileageEmployer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring O