Claims and Provider Manager Full-Time

This position is responsible for the coordination of all operational management activities related to the Claims and Providers Department. Will be responsible for directing and coordinating all aspects of Health Plan-Managed Care claims processes and Providers contracts. Works closely with the General Manager, the Managers of all other departments and Clients in order to effectively process and pay claims from members, providers and facilities in a timely manner and in compliance with public regulations.

Essential functions:

• Supervise and train all employees of the Claims and Providers Department, and oversees all the department’s functions, leading the department to be able to handle a high volume of claims;
• Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims and encounter processing and provider inquiries (written or verbal);
• Assure timely and accurate processing of claims and encounters, and respond to provider telephone calls, written inquiries, and appeals;
• The compilation of all information and documents required for claims processing and related inquiries to assure compliance with all applicable rules, regulations, and external and internal policies and procedures;
• The management and review of provider contracts and configuration of these contracts within the claims processing system to assure accurate payments to our providers;
• Collaboration and communication with other departments on claims and encounter issues, related projects and inter-departmental operations issues;
• Development and maintenance of well-defined processes to enter, adjust, manage and report claims and encounters data;
• Preparation and timely submission of management and regulatory reports;
• Generation of configuration requests to assure accurate, timely administration of providers claims and processing and reporting of encounters;
• Communication to all departments and personnel regarding claims and encounter information needed to perform their duties;
• Documentation of all departmental policies and procedures, following corporate standards;
• Maintain or exceeds all standards, as per the approved Plan accreditation bodies;
• Prioritize work and ensure all compliance elements are met;
• Maintain confidentiality of all patient information, as per personal data protection guidelines,
• Maintain a full comprehensive understanding of the covered benefits, coding and reimbursement policies and contracts;
• Participate and fully cooperate in the health plan’s accreditation efforts and audits;
• Ensure integrity of departmental database by thorough, timely and accurate entry, consistent with regulatory protocols and applicable Policies and Procedures;
• Analyse, track and trend claims and encounters data; identify any potential service or systems issues; implement interventions, and determine success of intervention;
• Production and submission of reports as required

Knowledge /Skills:

• Bachelor’s Degree from an accredited college or university required;
• 2 to 5 years of management experience. with demonstrated success in managing and motivating staff;
• 2 to 5 years claims management experience;
• Minimum of 3 years’ experience in healthcare, managed care or insurance industry environment required;
• Must possess solid communication skills;
• Willingness to adhere to all principles of confidentiality;
• Must value operating in a collaborative and cooperative environment;
• Ability to show initiative, good judgment, and resourcefulness.