Claims Inventory Manager (remote)

at  ConnectiCare

Summary of Job
Responsible for the oversight of the claims inventory management by our external vendor (CTS): develop, implement and manage the claims oversight department, to monitor and evaluate all aspects of claim inventory (volumes, age, quality, outcomes) for enterprise (HMO, CCI & PPO, Medical, Dental and Hospital) to ensure corporate objectives & targets are met. Ensure regulatory requirements and reporting needs are met to avoid penalties or sanctions. Analyze and report claims information including relevant health care trends and high cost claims by segment to business partners to ensure proper financial accruals. Report identified issues and opportunities immediately to vendor operations business partners via daily huddle; drive remediation as needed; communicate observations and findings to leadership, as well as other business partners. Ensure business partners are equipped with information necessary to respond to customer inquiries.

Responsibilities:

• Provide oversight of vendor and business partners’ performance related to the timely and proper disposition of claims: ensure first pass claims, claim adjustments and correspondence inventories are in compliance with policies, metrics and vendor SLAs.
• Validate vendor adherence to State and Federal regulation and mandates (i.e., prompt pay).
• Drive vendor and other business partners to ensure any specific client performance guarantees are being met (i.e. NYS Dental guarantee, FED VIP, FEHB Inquiry timeliness, etc.).
• Provide timely and direct feedback to vendor business partners on performance outcomes; actively question claims not in compliance with processing and timeliness standards.
• Actively participate and engage in corporate projects, PPM meetings, meetings and training regarding new mandates or changes to existing regulations.
• Act as subject matter expert (SME) as requested on projects.
• Ensure any changes needed to claim processing workflows and/or Desk Level Procedures are implemented timely.
• Track and evaluate vendor partners operational readiness for new project implementations, key program initiatives, regulatory changes and mandates.
• Review, verify and approve training timeline, desk level procedures and workflows for accuracy, completeness and compliance to ensure claims processing readiness.
• Champion communication and collaboration within areas of oversight and between internal stakeholders and key business partners to support overall EmblemHealth quality and customer service objectives; Implement corrective action plans for outcomes that are non-complaint more than 2 months in a row.
• Monitor and evaluate claim adjustment reason trends and identify strategies intended to reduce rework.
• Implement Process improvements through active engagement with business partners (EH & vendor) within operations as well as upstream and downstream departments.
• Collaborate with business partners on opportunities to improve processing efficiency and quality.
• Identify issues due to production breaks causing delays in timely adjudication and collaborate with the internal claim support team on root-cause analysis and fixes.
• Perform other duties as assigned and required by Claims Oversight Leadership.

Qualifications:

• Bachelor’s degree in Business Management
• 5 - 8 years related work experience (Required)
• 3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits (Required)
• 1-3 years’ experience managing in a BPASS model (Preferred)
• Additional years of experience may be considered in lieu of educational requirements (Required)
• Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications (Required)
• Facets experience (Preferred)
• Strong planning, organizational, interpersonal, verbal and written communication skills (Required)
• Must be PC literate and possess a strong understanding of Microsoft applications (Required)
• Ability to handle multiple priorities and meet deadlines (Required)

Additional Information

• Job Type: Standard
• Schedule: Full-time
• Employee Status: Regular
• Requisition ID: 1000001865
• Hiring Range: $72,000-$138,000

• Provide oversight of vendor and business partners’ performance related to the timely and proper disposition of claims: ensure first pass claims, claim adjustments and correspondence inventories are in compliance with policies, metrics and vendor SLAs.
• Validate vendor adherence to State and Federal regulation and mandates (i.e., prompt pay).
• Drive vendor and other business partners to ensure any specific client performance guarantees are being met (i.e. NYS Dental guarantee, FED VIP, FEHB Inquiry timeliness, etc.).
• Provide timely and direct feedback to vendor business partners on performance outcomes; actively question claims not in compliance with processing and timeliness standards.
• Actively participate and engage in corporate projects, PPM meetings, meetings and training regarding new mandates or changes to existing regulations.
• Act as subject matter expert (SME) as requested on projects.
• Ensure any changes needed to claim processing workflows and/or Desk Level Procedures are implemented timely.
• Track and evaluate vendor partners operational readiness for new project implementations, key program initiatives, regulatory changes and mandates.
• Review, verify and approve training timeline, desk level procedures and workflows for accuracy, completeness and compliance to ensure claims processing readiness.
• Champion communication and collaboration within areas of oversight and between internal stakeholders and key business partners to support overall EmblemHealth quality and customer service objectives; Implement corrective action plans for outcomes that are non-complaint more than 2 months in a row.
• Monitor and evaluate claim adjustment reason trends and identify strategies intended to reduce rework.
• Implement Process improvements through active engagement with business partners (EH & vendor) within operations as well as upstream and downstream departments.
• Collaborate with business partners on opportunities to improve processing efficiency and quality.
• Identify issues due to production breaks causing delays in timely adjudication and collaborate with the internal claim support team on root-cause analysis and fixes.
• Perform other duties as assigned and required by Claims Oversight Leadership