Senior Manager, Operations Claims
Apply NowCompany: Gold Coast Health Plan
Location: Camarillo, CA 93010
Description:
POSITION SUMMARY
The Sr. Manager of Operations has responsibility for providing leadership and management in the areas of claims-related services, including processing, auditing, research, and resolution, reporting and process improvement. This position will be responsible for the coordination of Gold Coast Health Plan's (GCHP"s) outsourced claims processing transaction functions as well as the overall daily management of GCHP"s internal Claims and Analytics team. The internal Claims and Analytics team's primary focus is on claims and operational analysis, research, projects, auditing, high dollar claims approval, partnering with the G&A department with Provider Disputes and supporting all other GCHP departments, while transaction processing and adjustments is performed by GCHP's vendor. The Sr. Manager of Operations, Claims will ensure that the claims payment process adheres to regulatory requirements, that payments are made according to benefit and contract terms, and that providers have a high level of satisfaction with claims payment performance. The Manager reports directly to the Executive Director of Operations and partners with other departmental managers and external vendors on all strategic and tactical matters as they relate to provider claims and payments
ESSENTIAL FUNCTIONS
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
Essential Functions Statement(s)
Lead and direct the claims management process, driving execution of best practices and related initiatives designed to provide a high level of efficiency and accuracy.
Ensure the processing of claims payments adheres to regulatory requirements and that payments are made according to benefit and contract terms; work to minimize the volume of pended and adjusted claims
Ensure effective and efficient operational processes and regulation adherence including validation that all new policies and procedures are implemented
Provide subject matter expertise in project management and other areas of expertise
Lead, coordinate and complete operational improvement projects across various functional areas within and outside of Gold Coast Health Plan
Own end-to-end process improvement: including definition of need, project plans, status updates, reporting and achieving results
Establish operating metrics and daily, weekly, and monthly scorecards to manage ongoing operations
Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes, enhanced management reporting and identification of process improvements
Develop collaborative relationships with and confirms business partners can execute day-to-day responsibility for operations
Develop collaborative relationships with matrixed partners and vendors
Inform and advise management regarding California Department of Health Care Services' current trends, problems and activities to facilitate both short- and long-range strategic plans to improve operational performance
Own operational accountability for the successful system conversions, where applicable
Identify and resolve technical, operational, and organizational problems inside and outside health plan
Lead teams to resolve business problems that affect multiple functions or disciplines
Lead and influence staff by fostering teamwork and collaboration, driving employee engagement, and leveraging diversity and inclusion
Drive high-quality execution and operational excellence by communicating clear directions and expectations
Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate
Monitor and provide oversight to delegated entities with regard to claims compliance from a regulatory and contractual perspective
Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes and management reporting
Prepare requested materials for internal and external regulatory audits and legal requests
Address escalating claims issues from providers and members to facilitate resolution of problems in an accurate, timely, professional, and courteous manner
Manage, select, evaluate, train, lead and direct staff in support of strategic and business efforts; build an effective team and ensure appropriate staffing and staff development
Effectively translates strategic goals into specific operating and resource plans
Coordinate and supervise operational analyses and implementation support on major workflow and claim system modification.
Act as a consultant for senior management, related to reimbursement methodologies, regulatory requirements, and claims processing protocols
Work with recovery vendor to identify funds paid in error, recovery of those funds including reporting of outstanding balances and funds recovered
Lead teams to resolve business problems that affect multiple functions or disciplines
Manage and develop the annual budget for the claims department
Partner with leadership to maintain external contact with regulatory agencies, providers, delegated entities, community-based organizations, and other health plans in all issues relative to grievances and appeals
Knowledge of:
Principles and practices of health care service delivery and managed care, Medi-Cal eligibility, and benefits. Medical billing/coding (CPT, HCPCS, ICD-9 and ICD-10); COB/TPL regulations and guidelines.
Claims operations and supporting information systems; experience in developing and tracking performance metrics.
Principles, practices, techniques, and theories of claims administration and customer service for a government agency serving a diverse social and ethnic population.
State and federal regulations as they relate to Medi-Cal managed care and other related business and policies governing managed care issues.
Perform such other duties as assigned.
POSITION QUALIFICATIONS
Competency Statement(s)
Management Skills - Ability to organize and direct oneself and effectively supervise others.
Business Acumen - Ability to grasp and understand business concepts and issues.
Decision Making - Ability to make critical decisions while following company procedures.
Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
Interpersonal - Ability to get along well with a variety of personalities and individuals.
Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
Consensus Building - Ability to bring about group solidarity to achieve a goal.
Relationship Building - Ability to effectively build relationships with customers and co-workers.
Presentation Skills - Ability to effectively present information publicly.
Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
Judgment - The ability to formulate a sound decision using the available information.
Communication, Oral - Ability to communicate effectively with others using the spoken word.
Communication, Written - Ability to communicate in writing clearly and concisely.
Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
SKILLS & ABILITIES
Education:
Bachelor's Degree (four-year college or technical school): Preferred
Experience:
8 plus years of experience in professional-level experience in a claims processing department as a manager; Preferably in a Medi-Cal/Medicaid managed care plan: Required.
Excellent analytical ability, judgment and problem solving.
Ability to present complex information in an understandable and compelling manner. Communicate effectively and clearly in both verbal and written form.
Excellent understanding of claims regulatory requirements including but not limited to AB1455, AB97, COB and clinical editing (NCCI): Required
Prior experience with Meditrac claims processing system: strongly desired
Prior experience with Optum CES and Easy Group: strongly desired
Prior experience with MHK: strongly desired
Computer Skills: Advanced computer skills included in the MS Office products including Access.
Other Requirements:
Possession of, or ability to obtain, a valid appropriate California driver's license. Maintain a satisfactory driving record
Ability to:
Evaluate, understand, and interpret policies, procedures and regulations; develop/revise policies and procedures as required.
Develop and implement operational and service level goals. Remain knowledgeable of the health plan's benefit structure.
Manage projects and prioritize the resources to optimize the use of those resources to maximize effectiveness.
Effectively present complex information to diverse audiences.
Develop constructive and cooperative working relationships with others.
Select, motivate, and evaluate staff, and provide for their training and professional development. Work in a fast paced, diverse organization that is performance oriented.
Prepare clear and concise reports, correspondence, and other written materials. Maintain confidentiality regarding sensitive information.
The Sr. Manager of Operations has responsibility for providing leadership and management in the areas of claims-related services, including processing, auditing, research, and resolution, reporting and process improvement. This position will be responsible for the coordination of Gold Coast Health Plan's (GCHP"s) outsourced claims processing transaction functions as well as the overall daily management of GCHP"s internal Claims and Analytics team. The internal Claims and Analytics team's primary focus is on claims and operational analysis, research, projects, auditing, high dollar claims approval, partnering with the G&A department with Provider Disputes and supporting all other GCHP departments, while transaction processing and adjustments is performed by GCHP's vendor. The Sr. Manager of Operations, Claims will ensure that the claims payment process adheres to regulatory requirements, that payments are made according to benefit and contract terms, and that providers have a high level of satisfaction with claims payment performance. The Manager reports directly to the Executive Director of Operations and partners with other departmental managers and external vendors on all strategic and tactical matters as they relate to provider claims and payments
ESSENTIAL FUNCTIONS
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
Essential Functions Statement(s)
Lead and direct the claims management process, driving execution of best practices and related initiatives designed to provide a high level of efficiency and accuracy.
Ensure the processing of claims payments adheres to regulatory requirements and that payments are made according to benefit and contract terms; work to minimize the volume of pended and adjusted claims
Ensure effective and efficient operational processes and regulation adherence including validation that all new policies and procedures are implemented
Provide subject matter expertise in project management and other areas of expertise
Lead, coordinate and complete operational improvement projects across various functional areas within and outside of Gold Coast Health Plan
Own end-to-end process improvement: including definition of need, project plans, status updates, reporting and achieving results
Establish operating metrics and daily, weekly, and monthly scorecards to manage ongoing operations
Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes, enhanced management reporting and identification of process improvements
Develop collaborative relationships with and confirms business partners can execute day-to-day responsibility for operations
Develop collaborative relationships with matrixed partners and vendors
Inform and advise management regarding California Department of Health Care Services' current trends, problems and activities to facilitate both short- and long-range strategic plans to improve operational performance
Own operational accountability for the successful system conversions, where applicable
Identify and resolve technical, operational, and organizational problems inside and outside health plan
Lead teams to resolve business problems that affect multiple functions or disciplines
Lead and influence staff by fostering teamwork and collaboration, driving employee engagement, and leveraging diversity and inclusion
Drive high-quality execution and operational excellence by communicating clear directions and expectations
Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate
Monitor and provide oversight to delegated entities with regard to claims compliance from a regulatory and contractual perspective
Enhance the operational procedures, systems, and principles in the areas of information flow and management, business processes and management reporting
Prepare requested materials for internal and external regulatory audits and legal requests
Address escalating claims issues from providers and members to facilitate resolution of problems in an accurate, timely, professional, and courteous manner
Manage, select, evaluate, train, lead and direct staff in support of strategic and business efforts; build an effective team and ensure appropriate staffing and staff development
Effectively translates strategic goals into specific operating and resource plans
Coordinate and supervise operational analyses and implementation support on major workflow and claim system modification.
Act as a consultant for senior management, related to reimbursement methodologies, regulatory requirements, and claims processing protocols
Work with recovery vendor to identify funds paid in error, recovery of those funds including reporting of outstanding balances and funds recovered
Lead teams to resolve business problems that affect multiple functions or disciplines
Manage and develop the annual budget for the claims department
Partner with leadership to maintain external contact with regulatory agencies, providers, delegated entities, community-based organizations, and other health plans in all issues relative to grievances and appeals
Knowledge of:
Principles and practices of health care service delivery and managed care, Medi-Cal eligibility, and benefits. Medical billing/coding (CPT, HCPCS, ICD-9 and ICD-10); COB/TPL regulations and guidelines.
Claims operations and supporting information systems; experience in developing and tracking performance metrics.
Principles, practices, techniques, and theories of claims administration and customer service for a government agency serving a diverse social and ethnic population.
State and federal regulations as they relate to Medi-Cal managed care and other related business and policies governing managed care issues.
Perform such other duties as assigned.
POSITION QUALIFICATIONS
Competency Statement(s)
Management Skills - Ability to organize and direct oneself and effectively supervise others.
Business Acumen - Ability to grasp and understand business concepts and issues.
Decision Making - Ability to make critical decisions while following company procedures.
Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
Interpersonal - Ability to get along well with a variety of personalities and individuals.
Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
Consensus Building - Ability to bring about group solidarity to achieve a goal.
Relationship Building - Ability to effectively build relationships with customers and co-workers.
Presentation Skills - Ability to effectively present information publicly.
Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
Judgment - The ability to formulate a sound decision using the available information.
Communication, Oral - Ability to communicate effectively with others using the spoken word.
Communication, Written - Ability to communicate in writing clearly and concisely.
Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
SKILLS & ABILITIES
Education:
Bachelor's Degree (four-year college or technical school): Preferred
Experience:
8 plus years of experience in professional-level experience in a claims processing department as a manager; Preferably in a Medi-Cal/Medicaid managed care plan: Required.
Excellent analytical ability, judgment and problem solving.
Ability to present complex information in an understandable and compelling manner. Communicate effectively and clearly in both verbal and written form.
Excellent understanding of claims regulatory requirements including but not limited to AB1455, AB97, COB and clinical editing (NCCI): Required
Prior experience with Meditrac claims processing system: strongly desired
Prior experience with Optum CES and Easy Group: strongly desired
Prior experience with MHK: strongly desired
Computer Skills: Advanced computer skills included in the MS Office products including Access.
Other Requirements:
Possession of, or ability to obtain, a valid appropriate California driver's license. Maintain a satisfactory driving record
Ability to:
Evaluate, understand, and interpret policies, procedures and regulations; develop/revise policies and procedures as required.
Develop and implement operational and service level goals. Remain knowledgeable of the health plan's benefit structure.
Manage projects and prioritize the resources to optimize the use of those resources to maximize effectiveness.
Effectively present complex information to diverse audiences.
Develop constructive and cooperative working relationships with others.
Select, motivate, and evaluate staff, and provide for their training and professional development. Work in a fast paced, diverse organization that is performance oriented.
Prepare clear and concise reports, correspondence, and other written materials. Maintain confidentiality regarding sensitive information.