The Claims Manager directly reports to the Director of Managed Care & Network Development and is an integral member of the MSO. The Claims Manager is responsible for the analysis and management of claim files in the utmost of good faith in compliance with the rules, regulations and statutes of the State of California. Functions at a high level of expertise and competency, while consistently exercising good judgment and independent discretion. Serves as a mentor to the claims staff. Interacts with a multi-cultural population of diverse socioeconomic backgrounds, levels of education and ages.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
The Claims Manager is responsible for performing the following duties:
- Directly manages Claims Examiners and their claim files.
- Provides supervision and guidance on claim assignments, coverage analysis, establishment of and adherence to action plans in claim files, and appropriate resolution.
- Work with the examiner throughout the life of the claim
- Approves action plans in accordance with best practices
- Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of processing claims
- Frequently communicates with all appropriate parties involved with the claim
- Works closely with other members of leadership to ensure the efficient and effective resolution of issues.
- Is charged with managing pending claims, improving file quality and controlling department expenses.
- Provides staff training and development
- Maintains professional vendor relationships
- Actively executes appropriate claims activities to ensure consistent delivery of quality claims service
- Recommends staff payment and settlement authority for employees in unit
- Complies with state laws and regulations regarding claim handling
- Has a shared responsibility for department budget, which includes planning and ongoing management of salary and expenses
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
- Claims management as measured through aggressive action plans and overall supervision as measured by reduction in average paid and average age of cases at time of closing
- Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.
EDUCATION, EXPERIENCE AND QUALIFICATIONS
- Bachelor’s degree in business administration, public health, healthcare administration, or related field or equivalent experience
- Minimum 5 years of claim management and leadership experience.
- Ability to operate well under high-stress conditions and be extremely organized, paying high attention to detail.
- Ability to mentor and motivate subordinate staff
- In-depth knowledge of appropriate legal principles
- Strong negotiation skills
- Must be articulate, communicate professionally and effectively, both verbally and in writing; accurate spelling and grammar are necessary
- Strong organizational skills, detail orientation, ability to proactively and effectively handle multiple tasks.
- Proficiency with use of computers, basic programs and social media is required.
Send applications or resume to: CdcrCareers@clinicas.org Fax: 805-659-3217