Job Title: Assistant Claims Manager
Reports To: Claims Manager
Salary Range: $75,000.00 - $80,000.00 per year
This position is responsible for assisting the Claims Manager in providing daily support to the Claims Department. Ensure that the staff are following appropriate state and federal regulations and standard operating procedures. The Assistant Claims Manager must motivate staff, provide training or coaching, and be innovative in creating and updating processes and procedures when appropriate.
• Oversee, mentor and manage the Claims staff related to processes and policies.
• Update and streamline processes and policies when necessary using technology and other innovative techniques.
• Play an important and visible leadership role in Claims staff meetings including training and sharing knowledge related to coding and claims processing.
• Provide feedback to Claims trainers regarding training topics for staff and the implementation and updating of procedures and processes.
• Reviewing and updating Plan documents, SPD’s, SBC and Schedule of Benefits on an annual basis
• Present information about how claims are processed related to the benefit plan designs by participating in monthly Appeals Committee meetings, including but not limited to presenting cases when necessary.
• Review and respond to CMS/COB&R inquires for COB overpayments of claims. Determine primary/secondary status of patient.
• Liaison between case manager and claims department for utilization management, care management and specialty reviews.
• Responsible for Predetermination of Medical Claims not subject to Case management or Utilization management review.
• Responsible for time off approval and Saturday scheduling when necessary.
• Responsible for out of country claims investigation and processing.
• Attend and Participate in MOE Members Service meetings.
• Quickly and effectively investigate claims and authorize prompt payments on escalated claims issues from staff.
• Reviews forms for accuracy and completeness. Calls or writes to the insured party or others involved to secure missing information when necessary.
• Investigate claims as necessary, through use of physical evidence, securing testimony from relevant parties, and examining reports.
• Follow appropriate HIPAA guidelines related to patient privacy and confidentiality.
• Assist with interviewing and hiring potential candidates, if necessary.
• Test and verify new or enhanced system applications, if necessary.
• Other duties as assigned.
Education and Experience:
• A college degree preferred or equivalent business experience
• CPC (Certified Professional Coding) Certification required
• ICD-10 Experience and understanding required
• Medical terminology certification a plus but not required, experience and understanding required
• Dental processing experience is a plus but not required
Length of experience:
• 3 – 5 years of management or supervisory experience with an insurance company, welfare fund or TPA required.
• 3 – 5 years of claims processing experience with an insurance company, welfare fund or TPA required.
Specialized skills/technical knowledge:
• Must have strong leadership abilities and soft skills to support the necessary managerial tasks entailed.
• Must have excellent communication (written, verbal, listening), organizational, and problem-solving skills.
• Must have an excellent grasp of medical terminology and anatomy knowledge.
• Must be able to read and interpret medical records.
• Must be able to understand and interpret Plan language including but not limited to Plan documents, SPD’s, SBC and Schedules of Benefits.
• Must have experience with COB including Medicare.
• Must have knowledge of healthcare coding systems and methodologies such as CPT, HCPCS, ICD-10 and DRG.
• Must be able to handle a high quality and production environment.
• Must be proficient in Microsoft Office applications and be able to use them as part of training, documentation and presentation.
• Must be reliable and a team player.
• Experience with BCBS and Blue Card claims processing and Labor Accounts a plus
• Knowledge of ISSI or similar claim processing systems a plus.
• Appropriate office phone etiquette.
• Ability to handle multiple tasks in a fast-paced environment.
• Ability to work independently and meet deadlines.
• Ability to be detail oriented.
• Must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier and telephone.
• Ability to resolve conflict.
• Ability to deal with stressful situations involving customer payments.
• Exhibits professionalism and positive attitude.
Please send your resume to: firstname.lastname@example.org and email@example.com