The primary purpose of this position is to oversee claims functions for the organization.
· Develops, manages, evaluates and is responsible for all activities within assigned scope of authority. Ensures accuracy and productivity achieves/exceeds Company standards.
· Plans and directs workflow to staff.
· Assists staff in resolving technical issues, process bottlenecks, and resource allocation situations.
· Sets goals and objectives for the department and staff; ensures that department results meet/exceed department performance standards.
· Oversees audit processes, policy and procedure development, new business implementation, and operational guidelines.
· Prepares routine reports of department results, goals, service levels, resources and challenges.
· Evaluates staffing and resource needs and makes recommendations to Director, Claims.
· Recruits, interviews and recommends the hiring of new staff members.
· Evaluates performance, provides constructive feedback, conducts counseling and training sessions, and supports staff in the accomplishment of assigned objectives and projects.
· Reviews and approves expenses within scope of authority.
· Develops spirit of cooperation and understanding among staff.
· Supports corporate quality improvement processes and ensures compliance with regulatory, accreditation, and health plan delegation standards.
· Recognizes unique and/or problem situations within assigned area of responsibility, researches, and formulates solutions in conjunction with Director, Claims.
· Maintains confidentiality of all member, provider, client and proprietary information.
· Participates with other members of management to discuss, develop, and implement operational and organizational processes within the company.
· Represents Claims when establishing and analyzing new and existing processes.
· Provides recommendations and input in developing organizational goals, strategies, budgets, and other long and short term planning matters.
· Works with Information Systems to enhance automation and systems efficiency.
· Serves on committees, workgroups, and project teams as assigned.
· Supports inter-departmental communication and teamwork to accomplish corporate objectives.
· Performs other duties and responsibilities as assigned.
· Bachelors degree in Business or equivalent.
· Five years of progressive experience in healthcare administration or operations, three of which have been in a management capacity.
· Thorough understanding of Managed Care (HMO, PPO, POS and related plans) required.
· Familiarity with Managed Care, HMO, PPO health plan provisions.
· Knowledge of HCFA regulations, medical terminology, CPT and ICD-9 coding, and claims best practices.
· Computer experience in word processing, spreadsheets, email and related software systems.
· Strong project management, organization, customer service, problem solving and verbal/written communication skills.
· Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
· Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
· Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
· Ability to effectively organize, prioritize, multi-task and manage time.
· Demonstrated accuracy and productivity in a changing environment with constant interruptions.
· Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
· Ability to exercise strict confidentiality in all matters.
Mobility: Primarily sedentary, able to sit for long periods of time.
Physical Requirements: Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.
Environmental Conditions: Usual office setting.