Claims Adjudication Manager

Position Summary:

Provides direction to the Claims Unit team while monitoring daily workflows, examiner assignments and production, and ensuring compliance with health plan and regulatory requirements.

Job Duties and Essential Functions:

1. Responsible for compliance of all claims regardless of department where the claim is pending.
2. Monitors inventory reports and assigns work queues based on staffing and/or volume re-assess, identifies and distributes unprocessed work to staff on a first-in first-out basis or other established priorities.
3. Works collectively with all levels of management and staff to ensure compliance with inventory production and timeliness standards including but not limited to QC, T&C, Eligibility, UM, Compliance, and Operations Departments.
4. Reviews daily operational reports throughout the day to assure compliance.
5. Maintains controls to insure that all claims are processed within regulatory requirements.
6. Reviews daily production reports to monitor and counsel staff not meeting the established production requirements.
7. Reviews monthly report cards to train and counsel staff that is consistently not meeting quality standards.
8. Identifies training for staff failing to meet established minimum production and quality objectives.
9. Updates and implements department training materials, approved policies and procedures, and such other approved reference materials as may be required for performance of the examiner’s job functions.
10. Holds regular unit meetings to review new policies and procedures and training issues.
11. Completes Corrective Action Plans for the Claims department by the requested due dates.
12. Maintains and keeps in total confidence, all files, documents and records that pertain to the operation of the business.
13. Attends internal and external meetings/trainings as necessary.
14. Manages staff hours and attendance
15. Assesses inventory vs. resources and provides overtime and inventory reduction plans when necessary
16. Available to work extended hours and weekends.

Experience/Skills Requirements:

Over 5 years experience in processing managed care health claims. Must have good understanding of various coding concepts (ICD9 CM, HCPCS, CPT, ASC, etc.). Requires a working knowledge of managed care concepts and regulatory requirements, particularly as relates to timeliness. Must have keyboarding skills and ability to read and write English. Must be able to assess work volumes versus resources. Needs to be able to communicate in a clear and concise manner. Needs basic understanding of word processing and spreadsheet applications; Microsoft Office experience is preferred. Must have keyboarding skills. Must have strong written and verbal communication skills. Must possess problem solving abilities and the ability to multi-task in a demanding environment.

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