The incumbent is responsible to ensure the accurate and timely payment of claims for the health plan according to health plan procedures, Department procedures, State and Federal Regulations and Laws, member benefits and provider contractual agreements. In order to accomplish this task this position shall ensure appropriate staffing and staffing responsibilities are maintained in order to meet the Department and health plan objectives. This position shall ensure an appropriate training program is in place for Department staff. This position shall ensure an appropriate audit program is in place for Department Claims staff.
- Ensuring the appropriate workflows and automated systems are in place to ensure claims are processed timely and accurately.
- Ensure claim payments are issued in accordance with contracted fees and guidelines.
- Define and implement projects that will improve the cost effectiveness and quality of claims processing, including Document Control.
- Manage and monitor the status of all claims related services, claim inventory and aging
- Define, develop and analyze reports and statistics that monitor Departmental performance and claims processing accuracy.
- Establish operating standards of performance including training and auditing requirements.
- Resolve issues related to pending and denied claims.
- Ensure the Coordination of Benefits (COB) and Subrogation areas of the Department.
- Develop and implement Subrogation procedures, which will include identifying third party claims liability, procedures for filing appropriate court documents and negotiation of settlements with attorneys in order to maximize subrogation recoveries.
- Ensure an appropriate education and training program is in place for Claims staff, including initial and subsequent programs.
- Ensure an appropriate audit program is in place for Claims staff.
- Will work closely with the Business Process Manager to coordinate, monitor and implement changes pertinent to the on-line claims processing system.
- Ensure appropriate Claims policies and procedures are developed and implemented.
Knowledge, Skills and Abilities:
* Excellent interpersonal and verbal/written communication skills required. Written and verbal skills shall include ability to make presentations.
* Ability to manage change and to obtain operational results with minimal disruptions through innovative and creative means.
* Ability to read, analyze and interpret general benefit, contract, systems, governmental regulations and develop claims and technical procedure manuals.
* Ability to calculate percentages/ratios to determine cycle time, accuracy/error rates of claims adjudication and other related functions and ability to compare these measurements to historical and industry benchmarks.
* Excellent analytical and problem-solving skills to identify problems, issues, errors and determine whether causes are of system, procedural and/or clerical in nature; ability to make recommendations for quality improvement and/or change management.
This position does not provide patient care.