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Claims Manager - Medicare

ggjdnw5ktczdjwzs076j6m1cjhquuh034ecrk99g0wv4jwssx3brqvzrftww6c1n · 30+ days ago

Atlanta, GA, US

$85k+
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Full-time

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Job Title: Claims Manager - Medicare
Job Location: Atlanta, GA (Brookhaven)
On-site/Remote/Hybrid: On-Site
Job Type: Direct Hire (FTE)

Summary:
The claims manager is responsible for managing the operations of the insurance claims department to meet the operational, financial and service requirements. The manager is responsible for mentoring, training and overseeing a team responsible for claims adjudication, provider payment processing and customer inquiries. Primary responsibilities will include overseeing a team of claims professionals, managing claims operations, and continually improving processes to enhance efficiency and customer satisfaction.

Qualifications:

Bachelor's degree or equivalent work experience
A minimum of 2 year(s):
- Supervisory experience
- Experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes
- Experience with CMS requirements, Skilled Nursing Facilities and other complex claim processing rules and regulations
- Experience in a managed healthcare environment related to claims processing/auditing, including Medicare plans
- Experience with complex claims processing and/or auditing within the health insurance industry or medical healthcare delivery system
- Leadership skills in the areas of claims staff development and performance improvement

Essential Duties and Responsibilities:

Manage and oversee all aspects of Medicare Supplement claims processing, ensuring accuracy and adherence to regulations and company policies.
Lead, motivate, and develop a team of claims examiners
Provide coaching and training to enhance team performance and knowledge.
Implement and maintain rigorous quality control measures to ensure the accuracy and consistency of claims processing.
Regularly conduct claims audits and reviews to identify trends, assess claim validity, and prevent fraud or abuse.
Stay up-to-date with Medicare and other relevant regulations, ensuring that the claims team remains compliant with all applicable laws and requirements.
Collaborate with other departments and teams to resolve customer inquiries, complaints, and escalations in a timely and satisfactory manner.
Establish and monitor key performance indicators (KPIs) to evaluate the performance of the claims team and drive continuous improvement.
Maintain accurate records and documentation of claims processes, decisions, and communication.
Identify opportunities for process improvements and automation to increase efficiency and reduce errors.
Provide regular reports and updates to senior management regarding the performance of the claims team.

Supervisory Responsibilities:

Strong working knowledge of claims processing standards, CMS claims processing requirements and various Medicare fee schedules
Proficient in processing / auditing claims for Medicare plans
Maintain required levels of production and quality standards established by management
Abide by departmental and organizational policies and procedures
Supervise claims examiner staff including scheduling and assigning work, reviewing performance, recommending salary increases, promotions or discharges
Training employees and providing a development plan for examiners
Addressing complaints and problems in regards to both processing issues
Monitor attendance and address personnel issues
Strong attention to detail and organizational skills
Develop claims reporting to measure and improve operational effectiveness

•

Last updated on Sep 15, 2023

About the company

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ggjdnw5ktczdjwzs076j6m1cjhquuh034ecrk99g0wv4jwssx3brqvzrftww6c1n

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