Claims and Customer Service Manager

The primary responsibilities of the Claims Manger are to train, manage, and mentor a team within the claim’s functions and Customer Service functions. The Claims Manager is also involved in meeting with vendors to ensure benefit programs will meet requirements for the department. This individual will report directly to the Fund Administrator. 
Responsibilities:

·    Supervise Claims and Customer Service staff in their day-to-day operations.

·    Assign, distribute and monitor quality and quantity of work produced by staff. 

·    Review all bills over $50,000.00 for release of claim.

·    Review and advise on all Supervisor referral forms. (Examples – possible cosmetic surgery/ review for additional R& C / CPT codes that are not in system / any services that are questionable.

·    Run varies reports for Trustees, Administrator, Consultants, and other various vendors. 

·    Review attorney letters. (Examples QMCSO / Divorce Decree / Power of Attorney / Reduction of lien requests etc.)

·    Manage Subpoenas. 

·    Gather lien amount totals and reports for fund attorney. 

·    Review and run 1099-M’s for ALL Funds.

·    Proof SPD’s and Plan Notices.

·    Prepare appeals for review. 

·    Assist members, clients, and vendors in a professional matter when needed. 

·    Ensure all requirements and program benefit changes are implemented and updated in the claims system.

·    Process all claims for all Union and Fund present and former employees. 

·    Submit stop-loss Claims and 50% notifications as well as track and balance stop-loss reimbursements.

·    Run daily claims batches and log counts by Fund.

·    Prepare requested information for Auditors and the DOL.

·    Respond to all Supervisor calls.

·    Maintain confidentiality.

·    Perform other duties as assigned.