Health Plan Claims Manager
Found in: Resume Library US A2 - 2 weeks ago
As the Claims Manager for Sendero Health Plan, a Health Maintenance Organization (HMO), and other Health Plans based in Texas, you will oversee the efficient and accurate processing of healthcare claims while ensuring compliance with regulatory requirements and company policies. Your leadership will be vital in managing a team of claims specialists, fostering a culture of excellence, and optimizing processes to enhance customer satisfaction.
Responsibilities:
Claims Processing Oversight: Supervise the end-to-end claims processing operations, including intake, adjudication, and payment processes, to ensure accuracy, timeliness, and compliance.
Team Leadership: Recruit, lead, mentor, and motivate a team of claim specialists to achieve performance targets, resolve complex issues, and maintain high productivity levels.
Quality Assurance: Implement and enforce quality assurance measures to uphold accuracy and consistency in claims processing, including regular audits and feedback mechanisms.
Compliance Management: Coordinate with the Compliance Department to stay abreast of federal and state compliance regulations governing the claims processing in the health plan industry, ensuring adherence to all legal requirements and company policies.
Provider Relations: Collaborate with the network providers and with the Sendero Network Team to resolve claims related inquiries, disputes, and grievances, fostering position relationships, and promoting efficient communication channels.
Performance Analysis: Analyze claims data and performance metrics to identify trends, root causes of errors, and opportunities for process improvement, implementing corrective actions as needed.
System Enhancements: Partner with IT teams to evaluate, test, and implement system enhancements or updates to streamline claims processing workflows and enhance system functionality.
Client Services: Ensure exceptional client service standards by promptly addressing inquiries, escalations, and complaints related to claims processing, striving to achieve high levels of member satisfaction. Prepare and review weekly claims reports with Clients to ensure accurate claim adjudications.
Essential Functions
Vendor Coordination: Coordinate with outside vendors to ensure their resources are managed to meet standards of operations for their contracted services.
Training and Development: Develop and deliver training programs for claims staff to enhance their technical skills, regulatory knowledge, and customer service abilities, fostering a culture of continuous learning and professional development.
Resource Management: Manage departmental budget, allocate resources effectively, and make strategic decisions to optimize operational efficiency and cost effectiveness.
Qualifications:
High School Diploma or equivalent Required
Bachelor's Degree Preferred
Work Experience
5 years Management or Supervision of a Health Plan Claims Department Required and
7 years Health Plan Claims Processing Required
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