The Claims Manager successfully manages the day-to-day operations of the Claim Department. This role involves managing a team of claims analysts and adjusters, ensuring accurate and timely processing of claims, and maintain a high level of customer satisfaction. The Claims Manager will develop and implement claims handling procedures, analyze claims data, and collaborate with other departments to optimize overall performance and efficiency. Performs all duties below while maintaining compliance and confidentiality and promoting the mission and philosophy of the organization.

ESSENTIAL FUNCTIONS:

• Successfully managing the day-to-day operations of the Curative Claims Department
• Serves as a key point of contact for audits, claims payments, questions, and customer service.
• Manage adequate levels of staffing to meet business needs.
• Ensure and provide consistent training, auditing, and feedback to all staff.
• Manage the Claims Team, work from home program, to ensure standards are consistently met.
• Conduct performance evaluations, provide feedback, and identify training needs.
• Resolve escalated issues and ensure team adherence to policies and procedures.
• Consistently ensure the Claims Team meets/exceeds the following standards:
• Claims processing turn around.
• Procedural and financial accuracy
• Pre-Release Client schedules
• Bank Processes, quality, and timeliness of files.
• ACH release approvals.
• Prepare daily, quarterly, yearly reports to internal staff and external staff clients.
• Manages yearly TDI and CMS Audit and Compliance and Invoice Requests
• Manage the repricing process for non-par and OON claims in accordance with turnaround time standards and client specifications.
• Responsible for the setup, review, and the reporting of reinsurance
• Work closely with IT, Medical Services, System Support, to ensure efficiencies.
• Work with HR, Executive and Accounting teams to define needed processes.
• FTP site administration for all clients document and claim requirements.
• Section 111 Administration setup and work with IT on file submissions
• HCRA Administration, as required/ requested by client.
• Review High Dollar Claims for completeness and accuracy and approves/ denies payment using established guidelines and making all required internal notifications.
• Clearly and concisely document claims adjudication decisions in Claim Notes.
• Works with the Claims Configuration Team to ensure proper benefit setup and enhance Auto Adjudication rates.
• Completes required sample of professional and facility claims to audit for accuracy, as required by the client.
• Completes focused audits for error trends identified during processing or pre-release audit.
• Identify claim analyst training opportunities and provider billing issues.
• Submits audit results to the COO for review.
• Acts as claims team resource for claims questions and benefit interpretation.
• Assists with and provides staff training via email alerts and training sessions.
• Reviews the results of all prospective and retrospective audits provided from various sources to ensure claims are processed, as mandated by client directives.
• Analyzes, tracks and trends provider, system setup and claim errors.
• Works on claims team projects, as assigned.
• Assists with all groups for claim processing.
• Attending departmental training when required or requested.
• Adheres to the rules and regulations of Curative as described in the Employee Handbook and as defined in the unit/department/clinic procedures.
• Performs other duties and projects assigned.

QUALIFICATIONS:

• High school diploma or equivalent. Bachelor’s or associate degree preferred.
• At least 5-10 years of Claims Management experience required, including HMO, PPO, ERISA, and governmental plan experience.
• Experience working with a variety of claims payment systems, processing of all claim types, to include hospital/facility, behavioral health, dental, vision, and professional medical claims. Experience working with the Health Edge claim system, VBA claims system. Customer Service experience preferred.
• Familiarity with Medicare facility pricing,
• Experience with Self-Funded, Fully Funded and Level Funded plans

Knowledge, Skills, and Abilities:

• Experience processing claims on the Health Edge system preferred.
• Ability to communicate with all levels of staff.
• Advanced Knowledge of claim coding and editing rules
• Knowledge of TDI regulations and requirements for claims payments
• Knowledge of HIPPA regulations
• Knowledge of medical terminology, ICD-10 CPT, and HCPCS coding.
• Proficient computer skills including Google sheets, Microsoft Office applications.
• Good verbal and written communication skills
• Ability to communicate clearly and effectively.
• Ability to sit for extended periods of time at a