Manager of Claims

Description

Job Title: Manager of Claims

Starting Salary: $83,256

Job Summary: Under the general supervision of the Chief Operating Officer, the Manager of Claims plans, controls, and implements departmental policies and procedures to ensure the orderly flow of the claims management.

Essential Functions:

• Provides input regarding the strategic decisions that affect the processing and payment of claims within the Claims Management (CM) Unit.
• Provides input into the development of the CM budget.
• Schedules internal and external audits on all claims issues and supervises this process.
• Develops and provides reports on audit findings and recommendations.
• Manages day to day workflow of claims management operations.
• Establishes policies and procedures for claims processing.
• Manages all employees of the department (adjudicators, supervisors) and is responsible for the performance management and hiring of the employees within the department.
• Reviews settled claims to determine that payments and settlements have been made in accordance with the OCHN’s practices and procedures.
• Verifies and analyzes data used in setting claims to ensure that claims are valid and that settlements are made according to OCHN’s practices and procedures.
• Reports on overpayments, underpayments, and other irregularities.
• Confers with legal counsel on claims requiring litigation
• Ensures compliance with CPT and ICD requirements.
• Analyzes account detail (charges, payments, adjustments) and answers detailed questions regarding claims payment or account status.
• Assists with pre-claim system edits that are produced due to a coding issue.
• Assists medical and behavioral health providers and employees with direction on the usage of specific diagnosis codes, CPT codes, and modifier or documentation requirements.
• Assists in PIHP/CMHSP encounter reporting, HCPCS and Revenue Codes along with CCBHC and integrated programs.
• Annually reviews and revies billing encounter forms making sure that all ICD and CPT codes are current and updated.
• Provides ongoing orientation to new employees and medical providers regarding coding and billing documentation and the Compliance Plan.
• Performs review of provider medical record documentation, financial information, and employee performance to monitor compliance with governmental and other third-party payor rules and regulations governing coding and billing.
• Assists in implementing the OCHN Compliance Plan to ensure correct and appropriate coding and billing.
• Identifies specific coding risk areas and strategies to promote accuracy, compliance, detection, and correction of potential risk exposures.
• Assists with educational and technical assistance programs for medical and behavioral health providers and clinical support staff.
• Participates with the OCHN Compliance Committee and other compliance activities.
• Participates with the OCHN Procedure Code Workgroup.
• Attends periodic conferences to maintain professional certifications.
• Responsible for the implementation and compliance with OCHN’s Health and Safety Policies.
• Performs related duties as assigned.

Job Requirements and Qualifications:

Education:

• A bachelor’s degree in business administration or a related field.

Training Requirements (licenses, programs, or certificates):

• Must have RHIT or CPC certification.
• Note: If the selected employee does not have this certification, that employee must receive the certification within six (6) months of the date of hire to maintain employment.

Experience Requirements:

• At least five (5) years of professional experience in outpatient, Medicare and Medicaid, computerized and manual billing for third party payors.
• At least three (3) years of supervisory experience in Claims Management.
• Note:
  • Experience as listed above may be substituted for education on a year for year basis.

Job Specific Competencies/Skills:

• Demonstrated effective interpersonal skills.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated effective negotiation skills.
• Demonstrated effective written and oral communication skills.
• Demonstrated effective computer skills.
• Demonstrated effective project management skills.

Managerial Competencies/Skills

• Ability to recognize and analyze complex operational/administrative or fiscal problems, and to recommend and implement solutions.
• Ability to work collaboratively and create a team environment that resolves problems and implements solutions in an environment that fosters system -wide continuous improvement.
• Ability to recruit, select, supervise, plan, direct, and evaluate the work of professional, administrative, and clerical employees.
• Ability to provide developmental opportunities for future succession planning and skill enhancement.
• Ability to communicate effectively, both orally and in writing.
• Ability to conduct effective meetings.
• Ability to initiate, plan, develop, coordinate and implement system wide programs.
• Highly effective project management skills.
• Highly effective interpersonal, active listening, negotiation, and conflict resolution skills.
• Ability to respond appropriately to and manage crisis situations.

Knowledge Requirements:

• Knowledge of Claims Management.
• Knowledge of the Billing Process including knowledge of computerized billing, electronic claims submissions, and outpatient billing procedures for third party carriers.
• Knowledge of coding CPT4 and ICD-9 and ICD-10.
• Knowledge of medical terminology and medical procedures as related to physician Medicaid, Medicare, and clinical support billing codes.

Oakland Community Health Network’s Core Competencies:

• Interacting with others in a way that gives them confidence in one’s intentions and those of the organization; demonstrating loyalty to the organization and its mission and values; maintaining social, ethical, and organizational norms; firmly adhering to codes of conduct and ethical principles. (Integrity/Building Trust)
• Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relationships, recognizing that the ultimate customer is the person served. (Customer Focus)
• Actively identifying new areas for learning; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill on the job and learning through their application. (Continuous Learning)
• Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence in addition to consciously adopting organizational standards of excellence. (Work Standards)
• Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message. (Communication)

Additional Information

(Travel required, physical requirements, on-call schedules, etc.):

• Must have available means of transportation to and from OCHN and for required offsite meetings or site visits.
• Must be available for meetings and events which may occur outside of standard office hours.
• Work performed primarily in an office environment.
• Hybrid (onsite/remote) work schedule available.
• The ideal candidate must be able to complete all the physical requirements of the job with or without a reasonable

OCHN is committed to building a diverse team and fostering an inclusive and equitable culture. We are proud to be an equal opportunity employer that embraces and encourages our employees’ differences. This includes (but is not limited to) ability, age, color, family type, gender expression and identity, individual expression, medical conditions, national origin, pregnancy, race, religion, sexual orientation, veteran status, and all other diverse and wonderful characteristics.