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. This includes 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

College degree or equivalent experience required in managed care or health insurance
Minimum of two years’ experience with Medicare claims adjudication preferred
Has successfully lead 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

Product Manager, Claim Adjudication – Medicaid/M Medicare

Key skills