Medical Claims Operations Manager
- Employer
- Benefit Management Administrators
- Location
- San Antonio, Texas
- Salary
- Not Specified
- Posted
- Feb 26, 2017
- Closes
- Mar 26, 2017
- Ref
- 2714915891#GIJ--J2CBackfill.1
- Category
- Claims
- Job Type
- Not Specified
- Career Level
- Not Specified
Job DescriptionManager, Claims Operations Department: Claims & Customer Service Department Reports to: President/CEO JOB SUMMARY: The Claims Manager acts as the primary resource for Benefit Management Administrators in regards to claims processing, coordination of benefits, subrogation, and is primarily responsible for the accurate and timely adjudication of all medical and dental claims. This position will oversee all daily claims processing operations and functions and is responsible to ensure timely and accurate processing of all medical and dental claims. Experience within healthcare insurance claims processing a must. The Claims Department Manager provides expertise and oversight for claim examiners within the department to include; administering claim payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. The Claims Department Manager monitors and controls backlog and work flow or claims and ensures that claims are settle in a timely fashion and in accordance with cost control standards. Accountable for compiling and submitting daily, weekly and monthly departmental reports to management. Acts as a technical expert in handling complaints and other escalated issues from internal and external customers. Participates in and supports the development of strategies to meet business needs. OVERVIEW: Create/Revise and implement medical payment policies with impact across the organization, including coding, medical necessity, organizational benefit, system, and member/group management as needed Oversee the Customer Service Department, Flexible Spending Account Departments, Stop Loss and Claims Departments Creation/implementation/renewal plan doc design, SBC s and plan summaries Predict emerging customers and product needs and develop innovative solutions to meet them Address and solve unique and complex healthcare adjudication issues within the department Interface with Leadership in shared service functions and other functional areas to ensure operational and leadership metrics are met Develop and maintain quality standards to drive efficiency and effectiveness within the operations ESSENTIAL DUTIES AND RESPONSIBILITIES: Oversee plan building in Claims System Address claim issues which become escalated Manage appeals Implement and Renew Plan Doc, SBC s and Plan IVR Summaries External audits Voids & Stop Pays as needed Refunds/Adjustment as needed Daily processing of claims edit/fraud/waste and abuse vendor/provider identified issues Daily production reports weekly or monthly (Flex, Claims and Customer Service) System/Processing training for Claims, Flex, Stop Loss and Customer Service Claims Processing high dollar claims (back up) Policy and Procedure creation and updates for Claims, Flex Spending, Stop Loss and Customer Service Provider and Vendor relations management as needed Supervisor escalated calls Pre-auth of service review (back up to analyst) Responsible for general management function of the claims/customer service team (includes Flexible Spending and Stop Loss) planning and organization Control claims cost through increased productivity and process improvement Process renewal and implementation of renewing/new groups JOB QUALIFICATIONS: General office/clerical knowledge, excellent customer service management skills, strong oral and written communication skills, experience working with confidential information. Knowledge of CPT codes and ICD10 codes 5-10 years management experience with ability to lead and guide team members Extensive knowledge of health insurance principles Excellent organizational skills KNOWLEDGE/SKILLS: High degree of management ability. Knowledge of self-funded employer health plans. The ability to apply knowledge, skills, and experience in medical/dental claims processing. Exercise a high degree of persuasiveness, tact, professionalism, problem solving, self-management and good judgments. EDUCATION: Bachelor s Degree or equivalent combination of education and industry experience is preferred. COMPENSATION: Competitive pay with employee benefit package. Health and Dental insurance premium covered by employer. Life Insurance, short & long term disability and 401K also available in addition to company wellness programs. Company DescriptionBenefit Management Administrators (BMA) is a San Antonio based Full Service Third Party Administrator (TPA) that provides contract administrative services for employer groups in need of Health Plan Administration, COBRA/HIPAA, Cafeteria Plan, Prescription Drug, Dental, Vision, Short Term Disability, Stop- Loss Procurement, Consulting Services and Transportation Benefits. For more information visit our website: