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Claims Operations Manager

4 weeks ago

Houston, Texas, United States Apex Health Solutions Full time
Job Summary

Apex Health Solutions is seeking a highly skilled Claims Operations Manager to oversee the adjudication and regulatory reporting functions of our claims processing system. This role is responsible for ensuring the timely and accurate processing of claims, as well as the development and implementation of operational efficiencies.

Key Responsibilities:

  • Establish and maintain consistent standards, practices, and processes for claims adjudication
  • Develop and implement strategies to improve claims processing efficiency and accuracy
  • Collaborate with stakeholders to ensure alignment of overall objectives and key requirements
  • Oversee user acceptance testing for any impacted changes to claims processing
  • Provide escalation support for business or revenue impacting performance or delivery issues within core business systems
  • Monitor claim inventory levels and implement control processes to ensure maximum production
  • Develop and maintain departmental policies and procedures according to current business needs and industry requirements

Requirements:

  • Bachelor's Degree or at least 7 years of commensurate experience in claims and healthcare administration
  • Strong knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, DSNP, etc...)
  • Extensive knowledge of claims policies and procedures including regulatory requirements and industry standards from AMA, CMS, and CCI edits
  • Strong computer skills, specifically with Microsoft Office and Windows
  • Excellent verbal and written communication skills
  • Ability to work independently on a variety of projects in a high volume, fast-paced environment

About Apex Health Solutions

Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Our unique solutions create alignment between payers and providers, generating unparalleled value. Combined with our experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction, and overall cost of care.