Medicare Advantage Claims Lead - Remote

We’ve made a lot of progress since opening the doors in 1942, but one thing has never changed – our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways.

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today!

This job leads and manages the claims delegation and oversight function along with claims processing reviews and issue resolution function within the organization’s health plan in accordance with established plans, standard operating procedures, and legal and regulatory requirements. Collaborates with the leadership team to inform strategy and ensure the operational effectiveness, financial success, and ongoing implementation of strategic goals and priorities. Works with the entire health plan team to investigate and resolve high level claims issues. Develops, implements, and monitors policies and procedures, executes on-going claims reviews while developing an in-depth understanding of the Facets claim system.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company’s discretion.

Education
Required – High School diploma or equivalent.
Preferred – Bachelor’s degree in business or healthcare administration.

Work Experience
Required – 5 years Medicare Advantage claims issue resolution, review and claims delegation oversight. Preferred – Experience with Facets claim system.

Certifications
Required – Certified Professional Coder.

Knowledge Skills and Abilities (KSAs)

• Proficiency in using computers, software, and web-based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally.
• Knowledge of Medicare Advantage Claims Processing guidelines, claims delegation, and Medicare claims repricing tools.
• Advanced organizational skills and ability to manage multiple projects, work under pressure with tight deadlines, be self-directed and work independently.
• Strong analytics and operational problem solving skills.

Job Duties

• Handles Medicare Advantage claims delegation and oversight function.
• Serves as a trainer and staff resource for claims, technical and program issues.
• Collaborates with Provider Services, Provider Relations, Claims and Configuration to reduce the impact of payment errors, implement process improvements and increase Provider satisfaction.
• Oversees delegated activities, including claims payment processes and regulatory compliance.
• Oversees internal controls activities, including routine and ad hoc reviews to identify and mitigate payment risks and financial errors.
• Performs reviews of claims, both pre and post processing.
• Works with delegated vendor to identify, trouble shoot and resolve claims issues.
• Completes claims reviews within established timeframes using Medicare Advantage claims guidelines and proactively informing management of potential underperformance in timeliness and quality.
• Develops reporting tools to communicate review outcomes to OHP team members along with Policy and Procedure development.
• Performs other related duties as assigned.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.
Physical and Environmental Demands
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 accommodations may be made to enable individuals with disabilities to perform the essential functions.

Sedentary Work – Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid.
The incumbent has no occupational risk for exposure to communicable diseases.

Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.

Are you ready to make a difference? Apply Today!

Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.

Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Washington, and New York.

Ochsner Health endeavors to make our site accessible to all users. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

We are proud to be an Equal Employment Opportunity and Affirmative Action employer. We are committed to the principles of equal employment opportunity and providing a workplace that is free from discrimination based on race, color, creed, religion, pregnancy status, pregnancy-related conditions, national origin, ancestry, mental or physical disability, medical condition, age, veteran status, military status, citizenship status, marital status, familial status, sexual orientation, gender, gender identity or expression, genetic information, political affiliation, unemployment status, or any other characteristic protected under applicable federal, state or local law. These protections extend to applicants and all employment related decisions. View the EEO is the Law poster and its supplement, as well as the pay transparency policy for more information.

Affirmative Action Policy Statement