Claims Manager - Imperial Health Plan : Job Details

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This range is provided by Imperial Health Plan of California, Inc.. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$90,000.00/yr - $95,000.00/yr

Direct and oversee the Claims Department and assign Claims staff to provide leadership with directions to ensure services are delivered accurately, timely, and in accordance with contractual and regulatory requirements to the client(s). Act as the primary liaison/consultant between clients, health plans, regulatory agencies, and Imperial Health teams, primarily system configuration and reporting, with regards to claims processing performance, accuracy, root cause analysis, systemic issues and failures as well as audits and corrective action plans. Participate in client on-site meetings as well as with internal and external operational teams, vendors, and necessary business associates.

ESSENTIAL JOB FUNCTIONS:

• Develop and maintain documentation, including policies, procedures, workflows, and training materials related to claims operations and encounter data submission.
• Ensure that claims payment system data, such as fee schedules and provider billing information, are accurately maintained and up to date.
• Tracks and reports daily claims inventory and productivity, compiling monthly or annual reports for leadership.
• Prepares and maintains reports on claims payment timeliness, inventory, production, high-dollar claims, errors/suspense, denials, and overall departmental performance.
• Oversee pending claims and monitor compliance with claims payment standards.
• Manages provider disputes, refunds, and system errors, conducting root-cause analyses and implementing corrective actions.
• Develop and implement a claims audit program to ensure accurate and timely claims payment in compliance with authorization and regulatory guidelines.
• Leads internal and external audits conducted by compliance departments, health plans, and regulatory agencies, drafting and executing corrective action plans as needed.
• Monitors electronic claims (EDI) processing to ensure timely and compliant claims handling.
• Oversees encounter data collection and collaborates with other departments to enhance accuracy and turnaround time.
• Works with the Finance Department on check-run processing and Explanation of Benefits (EOB) preparation.

Mid-Senior level

Full-time

Accounting/Auditing, Administrative, and Health Care Provider

Insurance, Medical Practices, and Hospitals and Health Care