[Hiring] Claims Operations Manager @Zing Health

Role Description

This position has responsibility and accountability for the implementation and ongoing support of Medicare claims operations across the Company. Responsible for ensuring that operational functions are compliant with Centers for Medicare & Medicaid Services (CMS) regulations for Medicare. Demonstrates knowledge of CMS regulations and operational monitoring activities to effectively perform duties that support the Medicare functions delegated by Medicare Advantage (MA) Plans. Demonstrates understanding of operational systems. Ensure that reporting is complete and accurate. Develops and assists in the implementation of operational policies and procedures. Investigates issues and recommends corrective actions as needed, to ensure compliance. Reviews policy and regulatory documents to identify the impact on operations. Responsible for working independently on assigned projects and tasks. Establishes effective relationships across multi-functional groups, providing guidance regarding Medicare Operations.

Essential Functions

• Oversee claims production and vendor oversight for Medicare Advantage line of business.
• Establish, implement, and provide improvements to internal controls and department policies and procedures.
• Maintain knowledge of government regulations as it pertains to claims payments and recognized claims processing standards.
• Investigate and respond to letters of inquiry on claims from members, providers, networks, and government agencies.
• Ensure adequate quality controls and participate with support departments to analyze the root cause of claim payment variations.
• Ensure claim support services achieve high provider satisfaction and timely dispute/appeal responsiveness.
• Interact with Core Configuration team and vendors to ensure claims systems are robust, compliant and support business developmental needs.
• Help to coordinate the implementation and maintenance of electronic data interchange (EDI) related to claims submissions and processing status.
• Work diligently to ensure accurate claims payment and associated documentation (remits). Identify trends and resolutions to reduce provider disputes.
• Monitor staff's work regularly for quality and efficiency. Provide training, feedback, coaching, and disciplinary action to staff, if necessary.
• Support staff in meeting standards, solving problems, and enhancing performance.
• Work collaboratively with other departments to resolve issues efficiently. Identify and communicate problems to senior leadership timely.
• Provide support and guidance to Medicare operations to ensure operations are compliant with MA Plan contractual requirements and CMS regulations.
• Monitor day-to-day performance and provide reports to MRx Compliance as required. Participate in ongoing operational and compliance audits.
• Participate in the planning, development and implementation of new accounts, programs, products and services, initiate and develop short- and long-range plans for department and participate in the development of corporate and strategic plans.
• Participate in implementation of Corrective Action Plans (CAPS).
• Assist Quality Improvement efforts in quarterly audits.

Qualifications

• Four (4) years minimum in a manager level role or above.
• Four (4) years of Medicare claims experience required, and Medicare/DSNP/ACA Exchange operations experience preferred.
• Seven (7) years of health plan administration experience.