We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.
Summary of role:
As a Claims Manager, you will be responsible for the oversight and management of health claims processing for our self-funded employer groups. You will have direct management of claim supervisors, subject matter experts (SME), Claims Analysts who are responsible for the accurate processing and ancillary support of health care claims on behalf of the employer plan and members benefits and will set and monitor productivity goals and claim quality metrics. You will work across functional teams within Centivo to manage and resolve dependencies impacting backlog and turnaround time goals and with Quality/Training and System Configuration teams to ensure standard processes are established, policies are enforced, and issues are mitigated through collaborative decision making.
Responsibilities Include:
Working under guidance of the Director- Claims Management, you will:
- Demonstrate knowledge and understanding of benefit administration for self-funded healthcare plans
- Directly support the client relationship and implementation process by being a collaborative partner with teams responsible for client facing issue resolution
- May be a direct point of contact for clients, vendors or providers that require relationship owners
- Ensure that metrics are established and monitored to ensure claims are processed and paid in accordance with benefit plans, pricing agreements, and required authorizations
- Manage the inventory of claims against standard service level agreements (SLA’s)
- Educate and mentors claims staff and to ensure proper application of client benefit plans to claims processed, at the required quality and production metrics, including establishing performance plans for those falling below expectations with appropriate coaching and mentoring to achieve improvement
- Provides reports to department leaders on claim inventory, production, turn-around lag, and quality metrics
- Create work plans to reduce claim inventory, including management of over-time hours that are appropriately monitored for cost effectiveness
- Develop policy and procedures to ensure that benefit plans and claim standards are properly administered; assists in developing policies and procedures for operations, and monitors claim staff for compliance
- Accountable for positively influencing the morale of the department employees, including setting achievable goals, fostering teamwork by involving team in the design/implementation of solutions to problems
- Responsible to establish annual goals for staff that align with organization strategies and personal growth and can provide timely and constructive feedback on performance
- A liaison for the claims on various projects and/or initiatives including testing needs to support system implementations and/or upgrades
- May also have direct ownership and responsibility for vendor and network partners, invoice management for vendors, overpayment and recovery process, subrogation and appeals management, external pricing strategies, and continual process improvement initiatives
- Performs other duties as deemed essential and necessary.
Qualifications:
Required Skills and Abilities:
- Proficient experience in MS Word, Excel, Outlook, and PowerPoint required
- Salesforce experience is a plus, high efficiency with tool is a bonus
- Understanding of health insurance benefit administration in a Self-Funded environment
- Strong leadership and team management skills, with the ability to communicate effectively with others
- Demonstrate abilities with process development and improvement as well as change management
- Ability to read and understand various forms, documentation, files, and information with the department
- Excellent verbal and written communication skills;…