Manager - Claims

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Location: 600 City Parkway West 10th Floor, Orange, CA 92868

Compensation: $105,000 - $125,000 / year

Job Title: Manager - Claims

Department: Ops - Claims Ops

We are currently seeking a highly motivated Claims Manager. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.

• Responsible for quality and performance metrics of processing team
• Manage claims inventory to minimize claims turnaround times and ensure contractual SLAs are met
• Drive continuous improvement efforts to improve claims quality and efficiency
• Resolve processing/system issues within assigned department
• Prioritize work volumes on a daily basis
• Oversee status of production in assigned department to ensure production and quality goals are being met
• Analyze impact of new implementations on assigned department and reallocate staff duties as necessary
• Utilize claims management systems to provide reports and analysis to management on a regular basis
• Develop team members to ensure accountability for achievement of departmental goals and objectives
• Update and facilitate implementation of process and workflow modifications to improve operational efficiency
• Educate and train claims employees on the overall claims process and best practices for successful outcomes
• EZCAP experience is a huge plus
• Telephone claim inquiries and claim payments by sensitive providers and members
• JOC meetings-attendance and corrective action response when required
• System updates maintaining the integrity of the Claims Payment Database; working inter-departmentally with other managers
• Off-site Seminars IE: E‑Z Cap and HMO Regulatory training.
• High level grievances or claim reconsideration request for reimbursable claim reviews
• Policies and Procedures- create and maintain an updated Claim Department Manual documenting and outlining DMHC/DHCS Regulations and CMS Guidelines claims workflow compliance
• Job Description s- format a standardized Claim Department Organizational Chart outlining performance responsibilities and requirements for each position
• Performance evaluation- monitors track and documents the annual performance evaluation of each Claim Department staff
• Recruit monitor, and document the attendance, production and work quality of Claim Department staff to include employee counseling and/or termination in accordance with HRIS Guidelines
• Staff analysis and growth potential
• Maintain open and effective channels of communication between staff and management
• Represent DMHC Regulatory and CMS Claims Payment Compliance issues at Management Meetings and with the Executive Board
• Using all tools available ( IE: Industry Communications, Seminars, Internet, Professional Networking) to maintain the most current levels of understanding of trends, occurrences, ideology and law that will affect the operation, compliance and stability of the Claims Department and of NMM. Communicate this information timely and effectively to both Claims Department Staff and to Management
• PDR and CSI Claims performance
• Maintains the strictest confidentially at all times
• Responsible for other miscellaneous assignments as requested by Management

• Minimum of a Bachelor's degree (B.
  
  A.) from a four-year college or university; or eight (8) years of claims processing or claims auditing experience, including four (4) years current Management experience with an MSO or IPA Management
• Full knowledge of DMHC, DHS and CMS Regulations and Guidelines, ICD-9, CPT, RV/RBRVS codes
• Experience with contract law and Division Responsibility matrix interpretation
• Comprehensive knowledge in the AB1455 regulations

• This is a remote position. The home office is aligned with your department at 600 City Parkway West 10th Floor, Orange, CA 92868.
• The target pay range for this role is between $ - $. This salary range represents our national target range for this role.

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Mid-Senior level

Full-time

Finance and Sales

Hospitals and Health Care

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need.

If you require assistance in applying for open positions due to a disability, please email us at humanre to request an accommodation.