What are the responsibilities and job description for the Medical Claims Manager position at PayerFusion Holdings LLC?
Job Description
Medical Claims Manager
We are looking for a Claims Manager that supervises and manages day-to-day claims operations, including claims evaluation, adjudication and customer service in accordance with agreed quality and production standards. Process claims in a timely manner and complies with industry fair claims practices and applicable state regulations concerning the processing of claims. Sets goals, while being accountable for the results. Manages staff of claims professionals, includes claims examiners, including the regular and timely evaluation of their performance. Maintains good, professional working relationship with superiors, peers, subordinates and other department managers and personnel.
About Us :
We are a service-based company and as a licensed third-party administrator, we are seeking only top talent and experienced personnel in order to meet and exceed our client's expectations. We're an innovative company creating a unique experience for healthcare professionals. While many industry-wide solutions exist, nothing comes close to our ground-breaking approach.
Duties & Responsibility :
- Supervise the claims departments to ensure proper workflow is conducted. Monitor timelines and constantly communicate via e-mail with clients to follow up on claims handling.
- Oversee Claims Examiner Department Responsible for searching the various networks and direct contracts database to determine the appropriate network that a claim should be processed through in order to secure the greatest savings to ensure clients continue to benefit from PayerFusion cost containment efforts. Meets deadlines promised to clients for claims processing.
- Review and perform quality assessments of work being released to clients to ensure claims processing errors are kept at a minimum. Identify claims that should be audited by the Medical Team when the total charges exceed the pre-established PayerFusion criteria.
- Coordinate and liaise with other departmental Supervisors as needed to ensure the operational process is followed. Identifies claims where little or no discount is available so that PayerFusion may attempt negotiations on these claims.
- Implement new procedures for new line of business. Train and cross-train all staff member with the Claims Handling Process and miscellaneous.
- Review & perform periodic quality assessments of work being released to the clients. Prepare reports as required.
- Provide clients with daily, weekly and or monthly updates on claims.
- Train new staff, also cross train existing staff
- Keep staff current about company, department and organizational issues, in addition to claims eligibility issues or procedures. This will be done via regular departmental meetings, one-on one communications and distribution of written directives.
- Advise management of any issues raised by staff and suggest actions that will improve processing or resolve the issues. Notify management on eligibility issues.
Knowledge of medical claims coding, different medical specialties and medical services billed for payment by providers to insurance companies is a must.
Bonus Points :
Benefits
