Job Description

Job Summary:

This position is responsible for directing the overall functions of claims processing, including claims adjudication, provider relations, data analysis, reporting and process improvement. Provides oversight and supervision of the claims team.

Essential Functions

• Responds to complaints in a prompt and professional manner and deploys effective service recovery strategies to resolve the issue. Escalates unresolved complaints when appropriate.
• Direct and coordinate the activities of claims and data entry areas including direct supervision of subordinates and the implementation of employment issues.
• Maintenance of a working knowledge of Management Information System and the coordination of required software enhancements for efficient claims processing.
• Assisting in the development and implementation of departmental policies and procedures
• Assurance of appropriate level of staff training
• Monitoring and documenting processing accuracy and productivity levels
• Preparing, submitting and monitoring various reports as required
• Oversee Medicare audit preparation, submission, and response processes, ensuring compliance with CMS regulations.
• Review, track, and manage Medicare audit findings, coordinating corrective action plans and validation activities.
• Ensure accurate Medicare coding, documentation integrity, and adherence to billing rules to minimize audit risk.
• Responsible for managing and responding to claim appeals, including Medicare-related appeals, ensuring timely and accurate resolution.
• Establishing department audit process and payment integrity
• Perform any other job related duties as requested.

Education and Experience

• Associates in business or related field required
• Bachelor's degree preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of healthcare claims experience required
• Previous financial experience in MLTC preferred
• Three (3) years Previous leadership experience required
• Experience with Medicare coding standards (ICD-10, CPT, HCPCS) and Medicare audit processes required

Competencies, Knowledge and Skills

• Advanced proficiency in Microsoft Word, Excel, and PowerPoint
• Data analysis and trending skills
• Experience in staffing and forecasting (preferred)
• Understanding of managed care claims operations
• Knowledge of coding and billing processes (CPT, ICD-9, HCPCS)
• Strong communication and negotiation skills
• Strategic and executive management abilities
• Supervisory and leadership experience
• Ability to work independently and collaboratively
• Attention to detail and critical thinking
• Familiarity with the healthcare field
• Technical writing and proper grammar usage
• Effective time management and decision-making skills
• Customer service orientation and proper phone etiquette

Licensure and Certification

• Medical Coding or billing certification preferred

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required

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