Sr. Coordinator, Manual Claims

Company

Work Schedule Description (e.g. M-F 8am to 5pm)

Remote Work Notification

Hiring Manager : Full Name: First Last

Overview

Due to growth, we are adding a Sr. Coordinator, Manual Claims Coach to our team!

The Sr. Coordinator, Manual Claims Coach ensures efforts are in alignment with the Claim Adjudication Operations (CAO) team to leverage technology and process improvement for the purpose of meeting the business needs of Navitus customers, clients, members, and pharmacies by accurately administering benefits. This position is responsible for processing of pharmacy and/or direct member reimbursement (DMR) claims of all levels of complexity to execute the claims adjudication process including correction of claims. 

The Sr. Coordinator, Manual Claims Coach will manage the day-to-day processes and changes made to a client’s benefit or a pharmacy’s contract. This role requires knowledge of both the technical and operational sides of the business. The Sr. Coordinator, Manual Claims Coach will have direct authority to make sound business decisions and will demonstrate the ability to continually prioritize day to day workload to meet individual, departmental, and organizational goals. The Sr. Coordinator, Manual Claims Coach will work closely with Member Services, Clinical Services, Client Services, Benefit Configuration, and Government Programs to understand the interdependences of each team pertaining to processing of claims.

This position may include after-hour and/or weekend hours depending on workload.

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team?

• Accurately processes claims within the claims adjudication system within specified client performance guarantee timeframes, guarding client and Navitus from potentially high dollar financial liabilities.
• Acquires and maintains an advanced to expert level of understanding of Navitus’ claims adjudication system, plan designs and upstream/downstream processes. Interprets client specific rules to ensure quality and accuracy of processing.
• Manages intake, scanning and categorization of inbound mail. Processes and mails outbound letters to members and pharmacies.
• Responsible for tracking and reporting on performance guarantees, NCQA standards, and monthly metrics.
• Learns and abides by HIPAA and other regulatory requirements to participate in client, compliance and state/federal audits including compilation of claim files, audit universes, report creation/analysis, validation of claims against benefit allowances and responding to auditor questions verbally and in writing.
• Participates in new client implementations and supports existing clients of high complexity, acting as the representative for manual claims in all related meetings and communications. Functions as a subject matter expert to assists Sales Support with proposal questions.
• Leads process improvement, cost reduction and automation efforts. Independently assesses future business needs and brings recommendations to leadership.
• Research root cause of issues, troubleshoots viable resolutions and makes recommendations for corrective action.
• Assists in the creation and ongoing maintenance of departmental training materials, work instructions and policies. Trains and mentors new and peer coordinators. 
• Communicates the nature of processing claims with all departments, providing talking points for Member Services to explain claim processing reimbursements to members and pharmacies, and Client Services or Government Programs to explain claim correction outcomes.
• Adapts to industry changes and evolving technology, maintaining an advanced to expert level of understanding of both legacy and emerging products and systems and conducts any relevant system enhancement and regression testing.
• Conducts system enhancement and regression testing for highly complex manual claims related processes to ensure compliance with state, federal and client regulations/standards.
• Supports internal customers by participating in client meetings, audits and new program implementations with other areas of the company, answering manual claims questions and providing guidance to other areas and roles on the manual claims process.  
• Provides support for client and sales presentations and responds to assigned RFP questions using subject matter expertise.
• Functions as a subject matter expert (SME), the main source of contact and lead peer mentor.
• Recommends, creates and conducts training within functional role for newer and experienced team members. 
• Monitors adherence to procedures and guidelines and reports performance to leadership.
• Other duties as assigned.

Qualifications

What our team expects from you?

• Associate’s degree or equivalent work experience required.
• Full mastery of Navitus systems and processes of the role with ability to perform tasks independently and follow instructions to make decisions required, typically with 4 or more years of experience.
• Experience with guiding and educating associates within current to lower-level roles.
• Experience within high-level planning and decision making.
• Experience with supporting highly complex/custom health plan business.
• Experience with the following tools at an advanced to expert level:
  • Navi-ClaimRx 
  • Microsoft Office (Word, Excel, Dynamics, CRM)
  • Request Management (Service Desk, Responsive)
  • Reporting (3D QlikView/QlikSense)
  • Government Programs Error Management (GEMS)
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

What can you expect from Navitus? 

• Top of the industry benefits for Health, Dental, and Vision insurance 
• 20 days paid time off 
• 4 weeks paid parental leave 
• 9 paid holidays 
• 401K company match of up to 5% - No vesting requirement 
• Adoption Assistance Program 
• Flexible Spending Account 
• Educational Assistance Plan and Professional Membership assistance 
• Referral Bonus Program – up to $750! 

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Pay Range