Manager, Claims Administration - Hybrid Remote
Fallon Health
2021-10-22T06:34:52Z
Worcester
Massachusetts
United States
Administrative / Clerical
(No Timezone Provided)
Overview
:
The Claims Administration Manager will be responsible for the overall operational leadership of the claims organization as well as maintaining CMS compliance. This role will also play an active role in the establishment of the organization, working closely with project teams responsible for the development and continued enhancement of the claims processing technical platform.
Responsibilities
Go-To person that serves as the company expert with CMS compliance - regulations, claims and audits. Regularly track group/departmental costs, ensuring these are managed within budget. Employ cost containment measures while retaining quality and efficient operations and a productive, healthy work environment. Anticipate expenses and identify potential budgetary concerns to Senior Director of Claims and Configuration. Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution. Implement, manage and refine business processes required to deliver expected business results. Implement short-term staffing plans to ensure anticipated operational requirements are met. Monitor the workload and adjust staff assignments accordingly. Ensure team has appropriate resources and highlights areas of need to Senior Director for resolution. Monitor the work environment and the business operation. Address concerns that may affect the morale and/or operational effectiveness of the group; Oversee managers and their role in developing and managing staff. Ensure objectives defined across a broader group are integrated and supportive where necessary. Hire for, develop and recognize the experience and knowledge/skills/abilities required for a successful team. Train and mentor staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc. Keep abreast of relevant CMS regulatory (pending and potential) updates. Identify and plan for potential impact to operations. Qualifications
Education:
Bachelor degree in business or other applicable field. Master's degree in business or other applicable field preferred.
Qualifications:
Minimum of five (5) years of claims and health care administration and/or managed care experience with managerial experience. Strong claims knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, PPO, PACE, Duals, FHW, etc.) Extensive knowledge of claims policies and procedures, including regulatory requirements and industry standards from AMA, CMS and CCI Edits. Strong Communication and Presentation skills. Strong Analytical Ability Extensive knowledge of federal and state regulations, legislation and laws, auditing reports and system functions; comparing functions with established standards. Ability to and experience in forecasting. Ability to perform root causal analysis and impact assessments with the goal of mitigation and/or process improvements Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
JT18
Manager, Claims Administration - Hybrid Remote
Administrative / Clerical
Overview
:
The Claims Administration Manager will be responsible for the overall operational leadership of the claims organization as well as maintaining CMS compliance. This role will also play an active role in the establishment of the organization, working closely with project teams responsible for the development and continued enhancement of the claims processing technical platform.
Responsibilities
Go-To person that serves as the company expert with CMS compliance - regulations, claims and audits. Regularly track group/departmental costs, ensuring these are managed within budget. Employ cost containment measures while retaining quality and efficient operations and a productive, healthy work environment. Anticipate expenses and identify potential budgetary concerns to Senior Director of Claims and Configuration. Regularly analyze and report on the productivity and effectiveness of the operations in comparison to established performance metrics. Identify areas of improvement and recommend resolution. Implement, manage and refine business processes required to deliver expected business results. Implement short-term staffing plans to ensure anticipated operational requirements are met. Monitor the workload and adjust staff assignments accordingly. Ensure team has appropriate resources and highlights areas of need to Senior Director for resolution. Monitor the work environment and the business operation. Address concerns that may affect the morale and/or operational effectiveness of the group; Oversee managers and their role in developing and managing staff. Ensure objectives defined across a broader group are integrated and supportive where necessary. Hire for, develop and recognize the experience and knowledge/skills/abilities required for a successful team. Train and mentor staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc. Keep abreast of relevant CMS regulatory (pending and potential) updates. Identify and plan for potential impact to operations. Qualifications
Education:
Bachelor degree in business or other applicable field. Master's degree in business or other applicable field preferred.
Qualifications:
Minimum of five (5) years of claims and health care administration and/or managed care experience with managerial experience. Strong claims knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, PPO, PACE, Duals, FHW, etc.) Extensive knowledge of claims policies and procedures, including regulatory requirements and industry standards from AMA, CMS and CCI Edits. Strong Communication and Presentation skills. Strong Analytical Ability Extensive knowledge of federal and state regulations, legislation and laws, auditing reports and system functions; comparing functions with established standards. Ability to and experience in forecasting. Ability to perform root causal analysis and impact assessments with the goal of mitigation and/or process improvements Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
JT18