Claims Manager

Top-rated Health Administration Company offers excellent opportunity to grow in a dynamic business. We are located in Katy, just off of Highway 99 and Westpark Tollway. We have been in business since 1970 and we are on the front lines of our industry.

Our new Claims Manager will be responsible for the overall direction, coordination and evaluation of our Claims Department. Involves “hands-on” daily interaction with all levels of staff and other relevant departments, particularly IT, Account Management, Stop Loss, Medical Help Line, Customer Service and Sales. Recommends and implements initiatives to improve department efficiency, productivity, workflows, and costs. Responsible for timely and accurate processing of claims and any support activity required to exceed customers’ expectations, Company standards and contract obligations.

Essential Functions and Responsibilities

Manage and supervise including but not limited to the following duties:

• Plans, organizes and manages Claims functions (including High Dollar Claims, Plan Build, ID Card creation and distribution, Provider, VBA testing. Works “on the floor” and coaches team members.
• Actively creates and implements strategy to increase the percentage of auto processed claims to 50%.
• Drives performance by ensuring all employees are trained, and work is completed in an accurate timely manner and meets company and contractual standards.
• Monitors and tracks staff performance against established productivity and quality metrics, including regular audits assessing department performance.
• Identifies and quickly acts on both positive and negative performance trends to ensure attainment of goals.
• Supports quality efforts including technical financial and processing accuracy, and conformity to Company standards. Addresses associate performance as needed.
• Monitors claims inventories, minimizes claims on hold, oversees work queues, ensures plan build inventories are completed by the effective date, prioritizes claims and exception situations as needed to ensure company standards and contract obligations are met. (Overall claims turnaround = 100% of claims 30 days; 90% of claims 14 days).
• Handles complex claims issues escalated by team members, groups, account management or others in the organization. Assists staff by developing solutions to issues, communicating appropriately and implementing methods for minimizing issues from recurring.
• Participates in daily, weekly and ad hoc cross-functional meetings to discuss and resolve operational and technical issues.
• Reviews claim audits for completeness, accuracy of information and compliance with our company’s policies, standards and procedures.
• Recommends changes to workflow, procedures or policies and ensures that all Claims employees are fully informed, understand and implement changes.
• Identifies, leads, develops and organizes training, re-training and cross-training of team members and new employees as appropriate and in coordination with Human Resources.
• Prepares and presents a variety of management reports, including explanation of variances, significant trends, and recommendations for change or resolution. Keeps leadership adequately informed of issues, trends, challenges, and problem identification/resolution.
• Partners with sales and account management to support creative benefit solutions, new client implementations and renewals, to ensure smooth and timely transition of new business.

Required Skills

• Minimum of 5 years supervisory and 3 years management experience preferred in a group health claims environment
• Working knowledge of current commercial health insurance product options, including HMO, PPO, EPO, high deductible plans, copay/coinsurance variations, and HRA’s/HSA’s.
• Expertise in claims adjudication, including interface with payers with or without delegation, eligibility and benefit determination, and member copay/coinsurance allowances.
• Strong understanding or experience working with stop loss carriers.
• Experience with and understanding of Direct Agreements with providers/facilities.
• Ability to effectively communicate with senior management, peers, supervisors and claims staff.
• Ability to create a team-oriented, positive, work environment and culture.
• Knowledge of CPT and ICD 10 coding.
• Excellent and effective business communication skills; both verbally and in writing.
• Computer efficiency in MS Office.
• Experience working in, and managing changing priorities, in a high volume, fast-paced work environment.
• Exceptional organizational skills and attention to detail
• Ability to strategically design and implement effective workflow and staffing plans
• VBA experience a plus.
• Exceptional organizational skills and attention to detail

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift

Work setting:

• Office
• Remote

Work Location: Remote