Manager, Claims Processing

POSITION SUMMARY

Responsible for the efficient and effective operations of the Claims department. Performs duties and responsibilities that include managing a team of both exempt and non-exempt employees, planning, coordinating, monitoring, and controlling claims processing work flow to to ensure quality (accuracy) metrics, claims timeliness, adherence to processing and contractual guidelines, customer Performance Guarantees, and weekly checkrun goals are maintained. Assists the Customer Service department with trained staff to assist as back-ups to handle incoming calls as workload dictates. Actively involved in company operations and corporate decision making. Builds and maintains effective working relationships with internal and external customers.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities

1.Management and Supervision

• Manages, plans, organize, trains, motivates and evaluates staff; including making hiring & termination decisions, assigning work, develop growth opportunities, conducting performance evaluations and taking corrective action. Communicates and assures that employees have a clear understanding of performance expectations and responsibilities.

Supervises/Manages the following staff:

• Manages staff in the Claims department consisting of exempt and non-exempt employees.

• Monitors employee performance and provides coaching and feedback.

• Conducts training for new employees and ongoing refresher training.

• Anticipates and plans for the future by analyzing claims data, assessing company and customer. requirements, determining skill levels, and assessing staffing/resource requirements.

2.Departmental Goals

• Effectively communicates to staff and monitors the stretch goals/performance measures and standards for the department in alignment with company-wide objectives/goals.

• Develop and maintain work processes and work review programs to ensure adherence to company and department accuracy and productivity standards.

• Establish accuracy and productivity standards, along with a routine monitoring process to ensure staff performance is aligned with company goals.

• Manage the weekly checkrun process to ensure operational goals are met for both Commercial and Medicaid checkruns.

• Plan, coordinate, and execute special projects for both the Commercial, Medicare, and Medicaid books of business.

• Develop and implement operational plans for Claims Processing that include best practice strategies and solutions to address current and future competition and business trends.

• Conduct system testing and support for Byte projects.

3.Policies/Procedures Manual

• Assists with the development and maintenance of departmental procedures manuals.

• Develops and implements claims processing policies and procedures, recommends changes to system rules and current policies, and offers solutions to address current and future competition and business trends.

• Document new and existing workflows.

4.Effectiveness/Efficiencies

• Ensures effective work processes and systems maximize operating efficiencies and increase the value of services provided in alignment with company goals and objectives.

• Provides control and oversight of system rules and outcomes for the claims adjudication system, evaluates system changes, documents policy changes, and trains staff.

• Identifies suggestions for system automation and enhancement to improve workflow efficiencies in claims Scanning, Data Entry, and Adjudication.

• Identifies process improvement opportunities, develops process documents, and works with other departments to implement improvements.

• Identifies training needs and develops and conducts training to maximize staff potential.

• Develops and maintains departmental performance measures, standards and reports (i.e., productivity, time and OT management and any other ad hoc reports.). Communicates and assures that employees have a clear understanding of performance expectations and responsibilities. Provide direction to staff as necessary. Continuously raise expectations and performance levels without sacrificing procedural integrity.

• Establishes work procedures and recommends system enhancements.

5.Internal Controls/Compliance

• Ensures controls satisfy operational/compliance risk requirements, and data integrity.

• Supports and participates in the internal and external audit processes for Dental Operations.

• Ensure controls, policies, and system checks and validations are in-place to support the compliance and risk requirements for the department.

• Establishes work procedures to ensure adherence to audit and claims monitoring controls and guidelines.

• Monitors and ensures staff compliance with company policies and procedures.

6.Customer Service (Internal/External)

• Monitors productivity and performance while ensuring professionalism, quality, timeliness and accuracy in accordance with overall company-wide objectives to ensure positive working relationships with internal and external customers.

• Works in collaboration with the Quality Assurance, Customer Service and Professional Relations departments to communicate and coordinate with our providers, members, and Sales teams to ensure special project commitments are met, group contracts are upheld, and our stakeholders (members and providers) are serviced in accordance with established policies and guidelines.

• Coordinates with Finance for payment recovery efforts, to implement stop payment mandates and to execute other payment related initiatives.

• Coordinates and collaborates with the ITS (Information Technology & Systems) department concerning system improvement/development projects for the department. Ensure that system testing is completed, organized and documented and systems/applications can be successfully implemented.

• Maintains relationships with counterparts in other departments to support and coordinate operations.

Other Duties and Responsibilities

• Advises on issues related to Dental Operations for Commercial, Medicare, and Medicaid operations.

• May serve as back up to Director of Dental Operations.

• Performs other related duties as required or assigned.

• May perform routine administrative tasks to meet operations goals and Customer Performance Guarantees.

MINIMUM QUALIFICATIONS AND EXPERIENCE

Education

Bachelor's degree in Business Administration, Public Health Administration or an equivalent combination of education, training or working experience.

Experience

Minimum of four (4) years of progressively responsible office administration experience, preferably in the areas of medical/dental (billing/claims/administration) servicing groups, group contracts and/or customer service.

Skills and Knowledge

• Ability to organize, analyze and problem-solve somewhat complex problems.

• Ability to handle multiple tasks and prioritize with some distractions and attention to details.

• Ability to communicate both orally and in writing with all levels of staff, customers, consultants/brokers, and vendors on sensitive matters.

• Technical knowledge to understand computer applications for problem-solving and answering staff questions (prefer Windows, Word, Excel, and PowerPoint).

Note: The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job. Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform the essential functions of this position.