Claims Program Manager
3 weeks ago
Job Title: Claims Program Manager - Payment Integrity Specialist
About the Role:
The Claims Program Manager - Payment Integrity Specialist will be responsible for identifying and transforming processes/procedures in the Claims department specific to payment integrity. This role requires interface with claims teams, payment integrity vendor(s), SIU, finance, and other applicable teams.
Key Responsibilities:
- Provide expertise bridging process and technology focusing on evolving functions, growing capacity, diversifying processes, and transforming the payment integrity aspect of claims, including increasing recovered dollars.
- Coordinate efforts with team leaders, project managers, and departments outside of claims to effectuate best outcomes.
- Analyze efficacy of documentation for the payment integrity program and transform documentation style to reflect adult learning aspects.
- Develop and socialize program strategies, changes, and future state within the team, with leadership, and with vendors.
- Collaborate with SIU to identify and investigate FWA, including representing claims in CMS investigations.
- Collaborate with leadership regarding annual strategy including roll out of new programs and processes.
- Manage vendors and reporting to leadership of all aspects of payment integrity program including multiple continuous and/or multi-year programs by planning project timeline and milestones, tracking progress, and monitoring/communicating project status.
- Make decisions regarding best practices, efficiencies, and implementation of decisions.
- Follow policies and procedures in order to maintain efficient and compliant operations.
- Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.
- Identify through analysis and judgement, providers with billing practices inconsistent with standards and make a determination regarding reporting provider to SIU, communicate bad actions to internal teams as appropriate.
- Contribute to overall department success by participating in department initiatives, effective communication, and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers.
Requirements:
- Bachelor's or Master's degree in business administration, Health Care Management, Education or related field of study.
- 5-7+ years in a communication role, experience with payment integrity, recoveries, TPL, OIC or other payment related operations, presentation experience including senior leaders, and health and welfare benefit experience.
- Health Insurance Benefits Management background in Medicare and Medicaid lines of business preferred.
- Familiar with Medicare and Medicaid resources and is proficient in producing research results via such resources.
- Knowledge of Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS) jurisdictions.
- Knowledge of HIPAA regulations and privacy laws.
- Communicate effectively and professionally with internal employees and external vendors (domestic and international).
- Develop, analyze, and present program reports for senior leaders.
- Develop process documentation reflecting an adult learning perspective.
- Deliver presentations to leadership groups, vendors, and team in a cohesive, consistent manner.
- Creative solutioning skills.
- Critical thinking.
- Decision making.
- Demonstrated experience working in fast-paced or implementation environment.
What We Offer:
- An annual employee bonus program.
- Robust Wellness Program.
- Generous paid-time-off (PTO).
- Eleven paid holidays per year, plus 1 additional floating holiday.
- Excellent 401(k) Retirement Saving Plan with employer match.
- Robust employee recognition program.
- Tuition reimbursement.
- A work-life balance.
About Us:
At SCAN, we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law.
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