Medical Claims Review Manager jobs in Garden Grove, CA

Job Description

Responsibilities/Duties:

• Provide an environment that allows staff members to flourish in their work duties. Quality levels of 99% maintained throughout the department.
• Continuous training of staff on responsibilities as well as on all enhancements and updates to claims regulations and company policies.
• Develop procedure changes to improve results. Corrective action plans developed and implemented to remediate any shortcomings in goal achievement.
• Maintain quality goals and production levels within the Department to ensure quality and production goals associated with each work area are consistently met by staff during their regularly scheduled work hours.
• Create, maintain and monitor departmental documents including policies, procedures, desktop procedures, workflow documents and job aids to ensure these documents are current and meet the requirements of Call the Car.
• Track and trend the metrics associated with the claims adjudication.
• Prepare and present written and verbal reports.
• Research complex problem areas within the department or within the systems used by department and identify the root cause of these issues and recommend corrective actions.
• Supervise staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
• Perform special projects and ad-hoc reporting as necessary. Projects will be complete, and reports will be generated within the specific time frame agreed upon at the time of assignment.
• Working with internal departments to resolve issues preventing claims processing or enhancing processing capabilities.
• Assist in testing, changing, analyzing and reporting of specific enhancements

• Any other duties as assigned by management.

Minimum Qualifications:

• High School diploma or GED Required.
• 4 years processing claims/invoices experience preferred.

• At least 3-5 years of experience as claims examiner working with medical facility claims
• At least 2-3 years of lead/supervisory experience.
• Experienced in working with Provider Dispute Resolution (PDR's).

• Must have extensive experience in handling claims appeals with experience in communicating with external providers.

• Sound understanding of health care code sets including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10 and revenue codes required.
• Familiarity with Diagnosis Related Group (DRG) pricing.
• Position requires the ability to multitask in a high production environment.
• Familiarity in working with and interpreting Provider contracts
• Ability to draw conclusions from data analysis and to formulate corrective action plans when necessary.
• Proficient in using Microsoft Word and Excel.
• Must have strong coaching and mentoring skills and have the ability to build effective teams.
• Must have excellent written and verbal communication skills with ability to work effectively with diverse team members.
• Ability to research complex claims problems and to create clear and concise procedures for the handling of complex claims.

• Must pass a Criminal Background Screening.
• Must pass government exclusion list at time of hire and monthly thereafter.
• Familiarity with various basic PC usage.
• Able to type at least 40 wpm.
• Availability to work any day and any shift; holidays and weekends.

All qualified applicants will receive consideration for employment without regard to race
To apply please email your resume to tmeans@ultimatestaffing.com