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Sr. Manager Claims (Remote)
FL, IL, IN and WI
AMA Insurance (AMAI) offers life, health and disability insurance at affordable and exclusive rates to help doctors achieve a healthy and secure financial future. AMAI is part of the American Medical Association (AMA), a nonprofit, and the nation's largest professional Association of physicians. We are a unifying voice and powerful ally for America's physicians, the patients they care for, and the promise of a healthier nation. To be part of the AMA is to be part of our Mission to promote the art and science of medicine and the betterment of public health.
At AMA, our mission to improve the health of the nation starts with our people. We foster an inclusive, people-first culture where every employee is empowered to perform at their best. Together, we advance meaningful change in health care and the communities we serve.
We encourage and support professional development for our employees, and we are dedicated to social responsibility. We invite you to learn more about us and we look forward to getting to know you.
We have an opportunity for a remote Sr. Manager Claims on our AMA Insurance team. This role will manage AMA Insurance Claims Department by establishing claims policesand managing all claims related data, processes and procedures for AMAInsurance. Responsible for the timely and accurate processing of claims,ensuring adherence to all carrier requirements and federal/state regulations..Serves as Agency subject matter expert and primary point of contact for allclaims related functions; working closely with internal and external businesspartners. Responsible for process improvement and the development andutilization of key processing metrics. Manages team of claims processors.
RESPONSIBILITIES:
Compliance

• Ensures AMAI remains in compliance with all claimsrelated processing; must adhere to all carrier and/or state regulatoryrequirements with regards to timeliness, accuracy, and payments.
• Leads annual carrier claims audits for Agency. Thisincludes gathering files/information, communicating findings, and workingdirectly with carrier audit team to resolve implement any required changes.Communicates findings with Agency senior management.
• Responsible for periodic regulatory updates requiredon a state level. Collaborates with Legal to understand changes and thenresponsible for updating processes.
• Responsible for accurately calculating benefits,benefit periods and interest calculations associated with claims payments asdefined by carrier requirements.
• Manages the internal AMAI claims review program;develops AMAI response on Claims reviews, complaints, and appeals; includesnecessary research and coordinating with Legal and Leadership as needed.
• Develops and implements processing changes as needed.

Claims WorkflowManagement

• Responsible for the development,implementation and management of procedures and workflows to ensure AMAI meetsall claims handling and compliance requirements throughout the entire claimlife cycle.
• Performs workload balancing dailybased on incoming claims volumes and staff capacity.
• Continually reviews team performancemetrics to identify any process or quality gaps based on claims departmentgoals and carrier Service Level Agreements.
• Develops claims data reporting andworkflow monitoring reports as needed to gain deeper insight into processingperformance; results to drive process improvements.
• Leads Claims and Customer Serviceteam response when handling complex customer service matters.
• Manage error resolution process (ex.issues with data file transfers), coordinating between AMAI IT and vendors (asneeded) to identify, fix, and if needed, update processes to prevent errorsfrom recurring.

RelationshipManagement

• Act as a primary contact on claimsrelated topic with partner carriers claims and compliance departments(including management teams); serves as an internal subject matter expert inboth AMAI processes and claims regulations.

• Manages the relationships with claimsprocess vendors; includes negotiating terms/pricing, leading problem resolutionwith vendor and/or AMAI IT; coordinating updates to processes, and providingexpert opinions.

Staff Management

• Lead, mentor, andprovide management oversight for staff.
• Responsible forsetting objectives, evaluating employee performance, and fostering acollaborative team environment.
• Responsible fordeveloping staff knowledge and skills to support career development.

May include other responsibilities as assigned
REQUIREMENTS:
1. Bachelor's degree preferred or equivalent work experience and HS diploma/equivalent education required.
2. 7+ years experience in health claims management.
3. Experience in people management required; able to attract and develop talent. Proven claims experience with multiple products including Medicare Supplement, major medical, hospital indemnity, life and disability insurance required.
4. Expert knowledge of medical terminology, ICD-9/ICD-10 codes, CPT/HCPCS and revenue codes required.
5. In-depth understanding of claims systems and electronic processing of medical claims (HIPAA ANSI 5010 electronic transactions) and imaging systems required.
6. Excellent organizational skills and attention to detail with the ability to manage multiple priorities and meet deadlines.
7. Ability to make sound judgments using strong critical thinking, analytical, research and problem-solving skills.
8. Demonstrated sense of discretion when handling confidential information.
9. Ability to effectively present information and respond to questions from staff, management, plan participants and business partners, using excellent verbal and written communications skills including creating and writing reports, business correspondence and procedure manuals.
This role is an exempt position, and the salary range for this position is $104,872 - $138,737. This is the lowest to highest salary we believe we would pay for this role at the time of this posting. An employee's pay within the salary range will be determined by a variety of factors including but not limited to business consideration and geographical location, as well as candidate qualifications, such as skills, education, and experience. Employees are also eligible to participate in an incentive plan. To learn more about the American Medical Association's benefits offerings,please click here.
We are an equal opportunity employer, committed to diversity in our workforce. All qualified applicants will receive consideration for employment. As an EOE/AA employer, the American Medical Association will not discriminate in its employment practices due to an applicant's race, color, religion, sex, age, national origin, sexual orientation, gender identity and veteran or disability status.
THE AMA IS COMMITTED TO IMPROVING THE HEALTH OF THE NATION