Regional Claims Manager jobs in Pomona, CA

Job Description

The Claims Manager will oversee the claims processors who are responsible for accurately and efficiently entering and processing claims/invoices for the organization.

This position will manage new program implementations and/or system implementations. This position must maintain an up-to date knowledge of national and state-wide standards and regulations pertaining to claims processes and will ensure that production standards meet quality guidelines are met throughout the department ensuring compliance. This position will work with department Supervisors and staff to develop procedures ensuring the achievement of goals and will continuously monitor the work performed within the Department.

The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.
REPORTS TO: Director of Finance or Designee

TYPICAL WORKING CONDITIONS: Office environment.

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 curren and accurate.
* 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:
* 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
* 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.

To apply please email your resume to agudiel@ultimatestaffing.com