Claim Department Jobs (NOW HIRING)

This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.   

Who Are We?  

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us?  

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

Under indirect supervision, manages and directs the processing staff activities of the Claims Department employees. This position ensures regulatory compliance in the processing of all inbound claims that are within the Centers for Medicare & Medicaid Services (CMS) regulations as well as Clever Care Health Plan policies and procedures as they apply to claims processing and payment. Assists claims employees in difficult calls, problem resolution and troubleshooting of claims issues ensuring that their employees effectively execute their day- to- day responsibilities in accordance with the Company’s claim business model and protocols. Identifies staff training needs and forward these to the Claims Manager for policy and job aid development.

Functions & Job Responsibilities

· 25% - Executes leadership supervisory functions for the claim unit; provides guidance and direction, managed daily inventory and processing activities, and identifies staff training development needs. Assists with developing and executing strategic and operational objectives related to timely processing goals for the Claim Department.

· 25% - Actively supervises the day-to-day operations of the claims unit. Maintains appropriate claims on daily inventory and reviews files in order to provide meaningful direction on claim management and resolution strategies that lead to better outcomes. Reviews settlement worksheets on a timely basis and provides payment direction in accordance with the Clever Care’s payment policies within established authority levels; makes recommendations and escalates payment requests above authority to Claim Manager. Reviews processing production on a timely basis and approves or makes adjustments as necessary; coaches employees on advanced processing practices and provides CMS related processing guidance to ensure accurate processing. Escalates payment and resource needs above authority to the Claim Manager.

· 20% - Provides guidance, support and growth opportunities to staff. Ensures that each employee has a meaningful professional development plan that supports the employee’s career goals. Manages the achievement of performance objectives for all direct reports; provides frequent feedback and meets with direct reports on a regular basis for meaningful coaching discussions on all aspects of the employee’s performance and development. Conducts meaningful annual performance reviews on a timely basis and makes salary adjustment recommendations to the Manager in accordance with the Clever Care salary administration plan. Effectively manages the progressive discipline process, including potential termination of an employee, in collaboration with the Claims Manager, Human Resources and appropriate members of the management team. Participates in interviewing and hiring of new staff and facilitates or conducts effective onboarding and orientation for new employees; coordinates with the Manager for development of formal training programs; assigns staff to special projects and oversees workflow and workload of staff.

· Completes other duties as assigned.

Secondary Functions:

· 5% - Assists in planning regular training programs to enhance technical, business and interpersonal skills of staff; communicates training opportunities to other departments.

· 5% - Assists with developing provider outreach and education on claims submission, payment processing, and explanation of benefits and payment. Reviews contracts and assists with system audit and validation in support of payment accuracy.

· 5% - Reviews and takes appropriate action on monthly reports, performance metrics and results, including the QA; evaluates and reports monthly unit results, making recommendations and adjustments when necessary.

· 5% - Facilitates and creates a team environment within the unit and with other departments; runs regular unit meetings, attends monthly claims review meetings and/or Clever Care meetings, as appropriate, in order to ensure effective communication between team members and disciplines.

· 5% - Identifies and coordinates external presentations that provide the Clever Care with positive public relations.

· 5% - Participates in a wide variety of special projects.

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values

• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining exciting and ennobling possibilities

• Enlist others in a common vision by appealing to shared aspirations

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve

• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships

• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence

• Celebrate the values and victories by creating a spirit of community

Required Qualifications

Education & Experience:

· Bachelor degree in Business, Insurance or related field required; Eight years of progressive claims experience can replace the Bachelor’s degree requirement.

· 5 years of progressive experience in claims or claims management; Medicare Claims experience required.

· 1-2 years of experience in a Lead or Supervisor required.

Skills:

· Ability to attend insurance and industry/business functions to promote and present a positive image of Clever Care; ability to participate in presentations to newly contracted providers; ability to travel as necessitated by business needs.

· Proficiency in EzCap and Microsoft Office computer applications; ability to learn new computer software applications.

· Advanced analytical ability: ability to analyze and interpret information to make well-informed decisions regarding claim handling strategies.

· Attention to detail in processing information, establishing priorities and meeting deadlines.

· Solid analytical and problem-solving skills including formulating logical and objective conclusions; the ability to think strategically.

· Ability to assess the urgency and importance of a situation and take appropriate action.

· Leadership ability with sound technical skills, analytical and problem solving ability, high ethical standards, good judgment and ability to effectively supervise staff.

· Ability to communicate effectively and professionally both verbally and in writing with various constituencies and at all levels, internally and externally.

Wage Range: $80,000 to $90,000 per year

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required

• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)

• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. 

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency. 

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