The Medicare Claims leader provides leadership and manages the day to day operations of several resources whose responsibility it is to manage the Claims processing. This leader also must have expertise with specialized knowledge in areas regarding claims processing, the Medicare Claims Managed Care Manual, prompt pay guidelines, and BlueCross Association claims rules. This includes oversight of daily claims pending inventory, claims compliance, and claim adjudication rules. This role is also accountable for managing reporting regarding claims payment accuracy and claims Medicare compliance.
- The essential functions listed represent the major duties of this role, additional duties may be assigned.
- Provides leadership and direction to three+ direct reports
- Manage level of performance by planning, coordinating and building an effective organization.
- Accurately coding of TNL and document monthly MBOs/Coaching in the talent management system.
- Responsible for meeting Medicare claims payment accuracy and compliance
- Lead and provide technical expertise for the planning and implementation of all Medicare claims projects.
- Serves as a primary resource for the interpretation of Medicare Managed Care and Chapter guidance for claims. This includes ensuring policies, procedures, standards and practices are adhered to meeting Medicare requirements.
- Develop, prioritize and implement strategies; set policies and procedures and manage creativity and innovation
- Oversee the daily pending claims inventory for Medicare claims including Audit, Medical Review and PIER
- Assist all lines of business with inventory management and help achieve their objective and goals.
- Review all claims that missed compliance requirements or did not pay accurately and create corrective action plans to re-mediate systemic issues.
- Research, analyze, validate and report financial data used for daily/monthly reporting to Senior Leaders
- Document procedures for system enhancements and/or improvements for Medicare claims
- Coordinate initiatives for continuous improvement and monitor and evaluate the effectiveness of solutions
- Maintains in-depth knowledge of new health products and requirements directly affecting Medicare Claims processing.
REQUIRED WORK EXPERIENCE
4+ years related work experience or equivalent combination of transferable experience and education. Experience Details: Claims' interest
Experience influencing and collaborating cross functional areas for effective business outcomes
Project management skills
Strong written and verbal communication skills including preparation of executive summaries
Experience with building and maintaining strong business relationships
Microsoft Office (i.e. Word, Excel, PowerPoint, Outlook) skills
Working knowledge of various lines of the business (i.e. NSA, COST, SAO and BlueCard)
REQUIRED MANAGEMENT EXPERIENCE:
2+ years direct supervisory/management experience
Related Bachelor's degree or additional related equivalent work experience
Master's degree Business Management
Knowledge of Medicare Advantage
Strong knowledge of Florida Prompt Pay Statutes
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Driving: Incidental Driving
We are an Equal Opportunity Employer/Protected Veteran/Disabled.