The Claims Manager position has primary responsibility and oversight for all Claims Processing functions for all business segments including timely and accurate processing per CMS and DMHC guidelines as well as policy and desk level procedures and assuring they are followed for claims functions.
Principal Duties and Responsibilities:
Support, manage and coordinate day to day activities of Claims Department by providing strong leadership to department supervisors and staff through 1 on 1 communication, team meetings, individual coaching, teaching and evaluating. Be available to staff on a daily basis to answer questions and provide support and guidance.
Responsible for human resource planning through staff selection, coaching, performance reviews and termination.
Establish and implement effective unit performance goals and measures that are aligned with business objectives. Provides ongoing monitoring and reporting of measurements.
Independently investigates complex claims and coverage issues bringing to resolution in a timely manner.
Works closely with other departments within organization on shared issues to effect positive change.
Continually search for and implement methods to improve overall operational efficiencies and processes to better manage total claims costs, and deliver superior customer service.
Provide interpretation of benefits, delegated contracts and provider contracts in matters regarding claim functions.
Promote compliance with all regulatory standards including CMS, DMHC, DHCS, and HIPAA
Bachelor's degree preferred or equivalent experience.