Manager of Claims Production
Neighborhood Health Plan of Rhode Island - Providence, RI

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Overview:

The primary responsibilities of the Manager of Claims Production are to:

1. Ensure that claims are processed according to state and federal regulations and meet Neighborhood’s contractual obligations, and

2. Ensure that claims are processed accurately according to Neighborhood’s contractual obligations and applicable regulatory guidelines, and to minimize unnecessary loss to Neighborhood by implementing effective claims audit and recovery programs.

The Manager is knowledgeable about all aspects of claims operations, including TPL, COB, claims auditing/editing and fraud & abuse activities and plans and allocates resources appropriately to meet changing business demands. The Manager is also knowledgeable about all aspects of the organization and is responsible for assessing the impact of new business on the claims function.

Qualifications:

Required:

- Minimum of Bachelors degree in business or health-related discipline, or sufficient experience and background to equate to the degree

- Minimum 4+ years of health care experience, preferably in managed care

- Extensive medical coding, physician billing, and fraud and abuse auditing experience; minimum of 3 years experience; in-depth knowledge of coding practices for professional and institutional claims

- 5+ years experience in claims processing with progressive increases in both experience and responsibility; working understanding of benefits, contract and transaction system adjudication knowledge required

- Knowledgeable of provider, facility and reimbursement mechanisms

- Strong PC abilities in Microsoft Word and Excel

- Strong process orientation and analytical capabilities, with demonstrated ability to implement change

- Knowledge of quality improvement process

- Demonstrated communication and interpersonal skills

- Strong customer service orientation; demonstrable negotiation skills

- Excellent organizational and troubleshooting skills

- Experience negotiating and managing external vendors

- Excellent written and verbal skills

- Team oriented

Preferred:

- 1+ year experience and comprehensive knowledge of COB, TPL and workers compensation claims processing

- Knowledge of Quality Improvement Process

- Coding certification

- Prior experience with all aspects of claims department operations a plus

- Medicaid, Medicare and commercial experience

- Project management experience

Duties and Responsibilities :

Responsible for managing the day-to-day operations of both the claims production functions:

- Manage inventory levels in both areas to ensure timely payment of claims and reconsiderations

- Work with Team Leads to manage claims functions delegated to outsourced vendor ( s)

- Maintain production and quality standards on each staff member and share with staff monthly

- Review inventory reports daily to monitor prompt pay and to track claims volume activity

- Manage the activities of team, which include identification of provider billing errors, identification of claim errors and communication of results to appropriate internal and external agencies.

- Ensure compliance of periodic reporting to EOHHS as required by the contract and other state / Federal regulations

- Oversee all aspects of contract implementation for impact on claims processing

- Initiate and recommend focused audits, system and process improvements to assist in the identification of opportunities for enhanced departmental performance

- Serve as claims production representative on internal teams when appropriate

- Identify new and improved methods to research, report, analyze and resolve claim processing inaccuracies and/or processes used in department

- Work with the Director to recommend changes, develop or modify policies and procedures to enhance teams and Neighborhood performance

- Responsible for the hiring and continuous coaching, training and supervision of the department staff

- Work with the Director to develop and monitor the annual Claims department budget

- Responsible for the timely and accurate processing of claims

- Coordinate and ensure timely and accurate implementation of special projects

- Monitor proposed/approved changes to state and federal law, assess the impact on claims operations and institute changes as required to remain compliant with regulations governing Neighborhood and its claims processing function ( e.g.: HIPAA, Prompt Claims Processing Act)

- In coordination with the Operation's Department Performance Support Specialists, develop and maintain policies and procedures relating to the claims processing function

- In accordance with and in coordination with ODHR policies and procedures, responsible for maintaining appropriate staffing levels, including the hiring and, if necessary, termination of employees

- Maintain an active participation on committees as required

- Other related duties and special projects as required or assigned

Neighborhood is an EOE M/F/D/V and an E-Verify Employer.

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The overall health of the people of Rhode Island is overseen by the Rhode Island Department of Health, which is overseen by a...