Health Plan Claims Manager - Austin, United States - Central Health

Description

Overview:

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 FunctionsVendor 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 RequiredBachelor's Degree PreferredWork Experience5 years Management or Supervision of a Health Plan Claims Department Required and7 years Health Plan Claims Processing Required#J-18808-Ljbffr