Manager, Claims Adjustments & MCA

Job Summary:

The Manager, Claims Adjustments & Mass Claim Adjustment (MCA) is responsible for providing leadership and direction to employees in the Claim Adjustment department to ensure the goals and standards of the department and CareSource are met.

Essential Functions:

• Manage staffing and scheduling functions to meet regulatory requirements and service level agreements (SLA’s)
• Oversee orientation and training of new team members and direct day-to-day staff activities to ensure service and performance objectives are achieved
• Engage direct reports through consistent performance feedback and development opportunities
• Manage and maintain reporting dashboards for inventory and root cause identification
• Have a deep understanding of the claim adjudication process to lead and develop team to increases in accurate automation of claims
• Manage claims adjustment automation through direction and oversight of MCA tool, robot automation tools, and manual adjustments
• Research and propose automation advancements; engage appropriate cross functional areas for solution development and implementation
• Ensure root cause identification occurs on adjustment ticket to identify and remediate claim system issues
• Prioritize tickets, projects, and escalations according to market and strategic needs
• Provide oversight of claim adjustment ticketing solution (OnBase, Service Now, SharePoint, Facets, TFS, email)
• Ensure claim adjustment team members identify, escalate and/or resolve complex or non-routine questions, issues, and problems within SLA timelines and provide direction as needed and/or escalate to senior management as appropriate
• Ensure that proper communication and approvals are in place prior to completion of tickets
• Manage communications on claim handling to ensure alignment, coordination, and strategic messaging (key areas of focus, key process changes impacting the process)
• Create consistency with respects to practices and processes for early identification of root cause, adjustment methods, and execution
• Collaborate closely with team, leadership, and cross functional teams on utilization of analytics, process automation and improving efficiencies
• Identify and facilitate process improvements to improve productivity, accuracy, and data usability
• Responsible for understanding industry advancements in claims processing and automation and identifying opportunities to leverage efficiencies for claim adjustments
• Collaborate with teams in Claims, Configuration, Claim Edits, Member Benefits, Utilization Management, Health Partnership, and around CareSource to ensure claims are processing appropriately based on the need of the entire claim payment lifecycle
• Assist in the development and implementation of departmental policies and procedures
• Oversee Claims initiatives such as working with IT and others to automate claims functions and improve front end processes, implement new business including the design, testing and delivery of supporting processes to the business
• Actively participate and partner with vendor management and procurement to secure effective and efficient vendor contracts
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in business administration, healthcare a related field or equivalent years of relevant work experience is required
• Four (4) years of healthcare claims or operations experience is required
• Two (2) years of previous leadership experience is required
• FACETS Claims experience required

Competencies, Knowledge and Skills:

• Working knowledge of medical claims workflow and processing applications
• Knowledge of regulatory reporting and compliance requirements for Medicaid and Medicare
• Knowledge of managed care industry, claims trends and best practices
• Knowledgeable in automating processes through RPA tools and techniques
• Familiar with Agile methodology and application
• Medicaid/Medicare knowledge of managing inventory and assigning work
• Proficient in Microsoft Word and Excel
• Knowledge of medical coding (CPT, HCPCS, ICD) highly desired
• Advanced working knowledge of managed care and health claims processing and reimbursement methodologies
• Ability to track/trend provider claim issues and develop solutions
• Excellent communication skills; both written and verbal
• Ability to work collaboratively with other management
• Time management skills; capable of multi-tasking and prioritizing work
• Effective decision making / critical thinking skills
• Ability to effectively interact with senior management and executive staff
• Strong business and financial acumen preferred

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business