JOB PURPOSE:
The Claims Operations Project Manager supports the Director in the day-to-day operations of the Claims Department. The position assists in the management of staff, claim processes and analysis, and vendor oversight to ensure compliance with federal and state guidelines and meets health plan regulatory and provider contract requirements as well as company objectives.
This position requires working knowledge of health care policy and payment methodologies along with strong organizational and analytical skills.
JOB RESPONSIBILITIES:
- Manage, in collaboration with the Director, functions related to claim processing, including monitoring of pending claims, appeals, recoupments, pricing, auditing, and reporting.
- Provide project management support in data collection and tracking in report building to meet the needs of the department and organization.
- Analyze, including root cause analysis, and claim data for reporting and process improvement.
- Formulate detailed analyses of payment trends that will provide accurate and actionable insight for configuration and edit changes. This includes but is not limited to DRG, APC, FFS, capitation, and VBP.
- Coordinate with Finance regarding check runs and provider payments, including refunds, overpayments, and underpayments.
- Conduct internal audits of department performance and external audits of vendor performance.
- Work with Compliance, Provider Relations, Care Delivery, and Business Development to ensure accurate claim outcomes and accurate and actionable insight for key decision-makers.
- Assist in the collection and preparation of data for applicable state, federal, and internal inquiries.
- Maintain organization of workflows related to TPA and internal operations impacting claim adjudication.
- Support staff in the management of appeals, provider projects, and ad hoc projects.
- Ensure a high level of customer service for internal and external customers.
- Ad-hoc projects as needed.
QUALIFICATIONS:
- BA/BS in Business, Health Administration, or related field required. 5+ years of experience preferred. 3 years of data analytics in a managed care setting is strongly preferred.
- Other:
- Project Management
- Strong knowledge of CPT, ICD9/ICD10, HCPCS, RBRVS, and revenue coding
- Working knowledge of contract interpretation and contract management
- Competent to strong Excel skills
- Knowledge and understanding of claims modifiers and their impact on payment
- Knowledge and understanding of 1500s, 1450s, and 837s
- Good working knowledge of health maintenance organizations and medical terminology
- Excellent verbal and written communication skills and the ability to effectively collaborate with other departments in the successful resolution of operational issues
- Strong organizational skills; commitment to customer service
- Ability to manage multiple projects and tasks
Physical Requirements
- Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:
- Standing – Duration of up to 6 hours a day.
- Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
- Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
- Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
- Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down and walk to access work areas.
- Agility/Fine Motor Skills – Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
- Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
- Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
- Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.
Job Type: Full-time
Pay: $105,000.00 – $115,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Flexible schedule
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Parental leave
- Tuition reimbursement
- Vision insurance
Physical setting: Office
Schedule:
- 8 hour shift
- Monday to Friday
Ability to commute/relocate: Flushing, NY 11354: Reliably commute or planning to relocate before starting work (Preferred)
Application Question(s):
What is your desired salary?
Education:
Bachelor’s (Preferred)
Experience:
- claims processing: 1 year (Preferred)
- CPT, ICD9/ICD10, HCPCS, RBRVS, and revenue coding: 1 year (Preferred)
- contract interpretation and contract management: 1 year (Preferred)
Work Location: Hybrid remote in Flushing, NY 11354
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