[Hiring] Product Manager, Claim Adjudication, Medicaid/Medicare @Navitus Health Solutions, LLC

Role Description

Due to growth, we are adding a Claims Adjudication Product Manager (CAPM) to our team. The Claims Adjudication Product Manager (CAPM) is responsible for ensuring Med D, Medicaid, and Exchange claims are adjudicating per CMS regulations as well as specific client needs. The CAPM will collaborate with other Navitus teams to ensure that the appropriate software, procedures, and oversight monitoring are implemented and operational in support of an environment of continuous improvements with claims adjudication.

Responsibilities

• Champion and maintain a proactive internal audit process to verify claims are adjudicating as expected.
• Conduct root cause analysis to minimize future defects.
• When adjudication issues are discovered, champion root cause analysis efforts of these issues in support of continually lowering our adjudication Defects per Million opportunities.
• Work closely with Recoveries Product Manager to verify recoveries projects produce the expected results as well as to improve the overall accuracy of the adjudication process.
• Oversee all adjudication-related fixes/enhancements, including oversight of system requirements development and testing.
• Ensure post-implementation monitoring processes are in place to validate adjudication-related fixes/enhancements are working as expected.
• Serve as subject matter expert for claims adjudication-related questions and system enhancements.
• Oversee timely completion of Acumen audit responses and leverage these results to improve claim adjudication accuracy.
• Ensure metrics are monitored and reported.
• Create and maintain claim adjudication training resources.
• Other duties as assigned.

Qualifications

• College degree or equivalent experience required in managed care or health insurance.
• Minimum of two years’ experience with Medicare claims adjudication preferred.
• Has successfully led root cause analysis projects.
• Project Management and/or Business Analyst experience a plus.
• Data analysis experience a plus.
• On-call availability.
• Some travel may be required.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance.
• 20 days paid time off.
• 4 weeks paid parental leave.
• 9 paid holidays.
• 401K company match of up to 5% - No vesting requirement.
• Adoption Assistance Program.
• Flexible Spending Account.
• Educational Assistance Plan and Professional Membership assistance.
• Referral Bonus Program – up to $750!