Claim Operations Manager

WHO WE ARE

Pacific Clinics is California’s largest community-based nonprofit provider of behavioral and mental health services and support. Our team of more than 2,000 employees speak 22 languages and are dedicated to offering hope and unlocking the full potential of individuals and families through culturally responsive, trauma-informed, research-based services for individuals and families from birth to older adults.

POSITION SUMMARY

Under the direction of the Corporate Director of Claims Operations, this position is responsible for overseeing, monitor, analyze, and ensure that claims have been submitted to the counties by the agreed upon timeframe. Responsibilities include the review and monitoring of claims which have been denied and not successfully adjudicated are corrected and resubmitted to healthcare payors in a timely fashion, also include ensuring the clients’ payor waterfall sequence is followed when claims are transferred, to prevent denials and enable successful claim adjudication.
The Claim Operations Manager will also be responsible for assuring eligibility verification is done regularly, based on the agency standards, to ensure the proper pay source sequence is reflected within the Electronic Health Record System (EHRS). The Claim Operations Manager will provide training and monitoring to ensure that written policy, procedures, and standards of practice are followed.

CORE ABILITIES

• Ability to analyze problems and implement acceptable solutions; identify issues, recommend appropriate resolution and ensure corrective actions have been implemented.
• Ability to extremely prioritize time sensitive documentation submissions; must be flexible, organized, and conscious of these timelines.
• Ability to communicate effectively with a competent and diverse population and promote favorable interaction with managers, co-workers, subordinates, and others, both orally and in writing.
• Ability to adapt and be flexible in a rapidly changing environment.
• Ability to be patient; accountable; proactive and take initiative.
• Ability to work effectively on a team; willingness to learn new topics, systems, and methods.
• Ability to independently solve problems, as well as analyze and resolve complex issues related to billing.
• Ability to work effectively and professionally in a multi-task and fast-paced environment with diverse staff and Agency demographics.
• Ability to effectively organize staff and work; demonstrate departmental leadership; appropriately handle conflict, based on the situation.
• Ability to develop strong team members and team, including hiring and/or terminating staff.
• Ability to effectively facilitate and lead efficient meetings, including time keeping, use of agendas and documenting follow-up items.
• Ability to develop and deliver effective staff training.
• Ability to take independent initiative and follow through with minimal direction.
• Ability to supervise, plan and direct the work of subordinate staff.
• Ability to manage financial and personnel resources in such a manner to ensure fulfillment of established goals and objectives.
• Knowledge of use of Windows OP/SYS, MS WORDS, EXCEL, Outlook, etc.
• Knowledge of OHC Billing procedures.
• Knowledge of Medicare Billing (Preferred).
• Knowledge of the healthcare service claiming workflow, preferably in Behavioral Healthcare using an EHRS.
• Basic knowledge of the healthcare claim payors, and the payor waterfall, including third party payors; preferably in Behavioral Healthcare.
• Knowledge of an Electronic Health Record System (EHRS) used in healthcare for billing clinical services
• Knowledge of the Healthcare Taxonomy / NPI structure and codes.
• Moderate Skills in databases (Access, Excel).
• Skilled in the use of the Windows file system, as well as Microsoft Word, Outlook, Access, and Excel applications with moderate to intermediate proficiency.
• Skilled in making decisions; using good judgment; dealing with ambiguity and change; producing high quality, detailed work; deductive reasoning, data analysis, and problem solving.
• Skilled in multi-tasking; improvising, with a creative approach to problems and obstacles; very detailed and results oriented and approaching tasks methodically.
• Skilled in following through on projects to achieve results; organizing and prioritizing competing deliverables; customer service, by phone and in person.
• Skilled in professional verbal & written communication.
• Skilled in managing, leading, directing, and supervising staff towards meeting an organization’s objectives.
• Initiate and maintain professional interactions and communication with Clinics’ employees and/or others.
• Position may represent agency at external meetings in the communities, county and/or funding source meetings.
• Maintain professional and effective working relationships, following all policies and procedures and approaching challenges with a proactive and positive attitude. Develop strong, trusted relationships with colleagues and customers.

EXPERIENCE / REQUIREMENTS

• College degree or five (5) years previous data entry experience in community mental health field preferably at supervisor or equivalent capacity.
• Two (2) years previous data entry work experience in healthcare EHRS billing
• Minimum (3) years’ experience in the areas of staff supervision, recruitment and performance management required.
• Other Health Coverage (OHC) billing experience and Medicare billing experience preferred.
• Must possess a valid California driver’s license and maintain an insurable driving record under the clinics’ liability policy (if driving two or more times per week on company business) OR if driving is not required, demonstrated ability to use public transportation or other means to travel between sites, if requested.

PHYSICAL REQUIREMENTS

While performing the duties of this job the employee is frequently required to stand or sit. The employee is required to use hands to produce records and/or documentation in manual or electronic format. The employee must regularly lift and/or move up to 5 pounds and occasionally move or lift up to 10 pounds.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Equal Opportunity Employer
We will consider for employment qualified Applicants with Criminal Histories in a manner consistent with ordinance 184652 Sec.189.04 (a) and San Francisco Police Code, Article 49. Section 4905.

• Oversee and monitor the timely submission of claims for the Northern region of Claim Operations for the various contracted counties.
• Ensure Billing Specialist accurately gather and post the cycles for claim submissions.
• Ensure claim submissions adhere to the specific county’s requirements and files were accepted for payment.
• Attend various county billing meetings to ensure the agency adheres to updates and changes in the claiming process.
• Communicate clear expectations and timelines to staff to meet internal and external deadlines
• Oversee, monitor, analyze, and ensure that all claims that have been denied by payors are corrected and resubmitted to healthcare payors in a timely fashion, which entails:
• Ensure denied claims are researched, resolved, and client payor information is adjusted in a timely fashion to meet key performance indicators.
• Ensure the claim denial reports are reviewed and the root cause and action steps are documented in the report to complete the denial procedure tracking; also assure the required action steps taken are documented by the due date for each report. Monitor “void claims” as a result of denials or eligibility changes, to ensure proper procedures and processes are followed.
• Ensure proper documentation and a record of each claim related action is documented; for example, record the reason for voiding or transferring payors on a claim, document the reason a payor is being changed, etc.
• Ensure appropriate corrective actions have been completed prior to the regular billing cycles.
• Consult with Corporate Director of Claims Operations and/or Program Team Supervisors and Program Directors regarding reoccurring issues, and escalate resolution to supervisor, Division and Corporate management as needed.
• Track and update claim tracking reports monthly for each specific county.
• Oversee the process of the month-end reports to accurately track the claims billed and reconcile with reports to provide monthly estimated billed amounts.
• Review, track, monitor and verify all void requests for accuracy and applicability per Agency guidelines including obtaining appropriate authorization to void billing and ensure void claims are received / processed by the payor.
• Independently monitor, analyze, identify, report, categorize, and investigate claim denial patterns and trends, in order to assist the agency to continuously improve / reduce the denial rates (as a % of claims submitted), working with providers, Client Data Admin department/Client Services Department and/or appropriate team members to improve these rates.
• Oversee claim eligibility verification, which entails:
• Ensure client eligibility verification results and reports are reviewed, and the appropriate payor is billed in the correct sequence by verifying the client’s payor waterfall set-up in the EHRS, as well as other necessary verification.
• Supervise the completion of Eligibility Reports (weekly and monthly) to ensure eligibility changes are reflected in Welligent Client Pay Source as soon as eligibility changes have been verified through the Medi-Cal Eligibility website.
• Develop and maintain written procedures regarding eligibility changes and related matters.
• Oversee, monitor, analyze, and ensure all claims that have been delayed due to errors categorized in EHRS as violations, unbilled services, and ungathered services, are corrected and submitted to healthcare payors in a timely fashion to meet key performance indicators, which entails:
• Ensure the claim error reports are completed and the required steps/actions taken are documented by the due date for each report, such as the Monthly Eligibility Report, Weekly Unbilled Report, and Weekly Violations report.
• Develop and maintain written procedures regarding errors and the corrective action of errors, including but not limited to: Welligent Violations and Unbilled Services Report, MSO Denials Report, Denied CalPM Report, etc.
• Ensure the accuracy of all data fields and pay source setup/changes during the error correction process.
• Conduct training and monitoring of all error reports including but not limited to: Welligent Violations and Unbilled Services Report, County Denials, State Denials Report, etc.
• Provide consultation and guidance regarding the corrective actions required, including researching errors to identify root cause, and required resolution per error source.
• Prepare weekly status reports that summarize billing errors by report type, explain error patterns and corrections if applicable, and identify system set-up issues.
• Propose and recommend EHRS system changes and enhancements to support claiming needs.
• Communicate any identified data anomalies to the Director in a timely manner.
• Provide backup support within the Team when requested. Backup all data entry duties in the event of staff absences and vacations.
• Attend appropriate site meetings, activities, and staff meetings upon request to provide input towards client data administration, billing procedures, program development and staff training.
• Attend job related, management and HR training as appropriate.
• Follow HIPAA policies.
• Perform all duties and work projects as assigned.
• Model Pacific clinics’ approach, mission and core values in all communication and correspondence.
• Communicate effectively in a competent and diverse consumer population and promote favorable interaction with managers, co-workers, and others.
• Maintain the confidentiality of all business documents and correspondence.
• Provide supervision, training, and support to the staff, as well as program staff that are performing data entry duties that impact claims processing and claims compliance.
• Coach and develop staff skills and knowledge for career advancement.
• Maintain data entry accuracy in compliance with the established Client Data Operations Key Performance Indicators (KPIs).
• Design, document, and maintain functional standardized workflows that impact billing, and monitor adherence to these workflows.
• Ensure effective staffing of all roles and identify issues that interfere with staff effectiveness and provide training, guidance or problem resolution as needed.
• Identify, communicate with, and hold staff accountable for meeting performance expectations / KPI’s; monitor/appraise the job results and performances and promote a positive, team-oriented work environment.
• Ensure that assignments are completed in a timely manner and within budget; focus self and others on achieving results.
• Ensure staff are trained on new work methods in response to new information, changing conditions, or business / KPI issues.
• Ensure the timely submission of all performance appraisals, new hire and termination paperwork and other employee status changes within the department including informing HR of employee leaves of absence, work-related injuries and employee incidents.
• Effectively and consistently communicate contract and compliance directives to staff. Encourages interactive discussions and maintain an open-door policy. Ensure that all staff within the department are properly educated and informed about matters relating to the agency, department, and division.
• Monitor key performance indicators for the Department.
• Ensure all staff follow the Health Insurance Portability Accountability Act (HIPAA) policy, maintain organized work areas, and follow Pacific Clinics standards.
• Perform other duties as assigned.