Sr. Manager Claims (Remote)

FL, IL, IN and WI

RESPONSIBILITIES: 

Compliance

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

Claims Workflow Management

• Responsible for the development, implementation and management of procedures and workflows to ensure AMAI meets all claims handling and compliance requirements throughout the entire claim life cycle.
• Performs workload balancing daily based on incoming claims volumes and staff capacity.
• Continually reviews team performance metrics to identify any process or quality gaps based on claims department goals and carrier Service Level Agreements.
• Develops claims data reporting and workflow monitoring reports as needed to gain deeper insight into processing performance; results to drive process improvements.
• Leads Claims and Customer Service team response when handling complex customer service matters.
• Manage error resolution process (ex. issues with data file transfers), coordinating between AMAI IT and vendors (as needed) to identify, fix, and if needed, update processes to prevent errors from recurring.

Relationship Management

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

• Manages the relationships with claims process vendors; includes negotiating terms/pricing, leading problem resolution with vendor and/or AMAI IT; coordinating updates to processes, and providing expert opinions.

Staff Management

• Lead, mentor, and provide management oversight for staff.
• Responsible for setting objectives, evaluating employee performance, and fostering a collaborative team environment.
• Responsible for developing 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.