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Form of work
SalaryJoin Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
Job Description
Key Outcomes:
- Establishes, monitors, and continuously improves processes and supporting policies and procedures to ensure the timely and accurate processing of claims.
- Responsible for ensuring the team complies with all model audit rule activities.
- Oversees the Audit and Recovery team, tracks and reports all savings identified and recovered.
- Consults and collaborates with the Director of Provider Operations to address issues contributing to inaccurate or inefficient processing of claims.
- Identifies and submits high dollar claim referrals to other departments and vendors.
- Provides vendor oversight and review and modification of vendor contracts. Manages vendor performance, and periodically surveys the market for alternative vendors.
- Ensures vendor adherence to all policies and determines the need for new policies.
- Oversees the development of annual department budgets consistent with strategic and financial goals.
- Prepares and maintains information pertaining to Martin’s Point’s FWA program and produces management reports.
- Prepares and facilitates requests for medical records to validate services rendered and claims submitted and evaluate the appropriateness of services/supplies billed.
- Initiates and maintains communication with regulatory agencies, including presenting or assisting in the presentation of investigations and case findings.
Education/Experience
- Bachelor’s degree preferred.
- 5 years management and/or leadership experience.
- Experience in a health plan operations claims environment.
Skills/Knowledge/Competencies (Behaviors):
- Knowledge of claims policies and procedures, including industry standards from Medicaid, CMS, and CCI Edits
- Advanced skills in medical terminology, CPT/ICD-9/10 coding is preferred
- Highly developed quantitative and qualitative analytical skills
- Ability to articulate goals, plan and implement processes, and meet deadlines
- Strong interpersonal skills, including professional communication, relationship building, and effective written and verbal communication
- Solid understanding of standard claims processing systems, operations, and claims data analysis
- Knowledge of HIPAA privacy regulation and rules necessary
- Proficiency with Microsoft Office Suite applications
This position offers the opportunity to work remotely with quarterly and as needed visits to Portland, Maine.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at:
jobinquiries@martinspoint.org
