Senior Manager – Claims

Role Overview

• Responsible for quality and performance metrics of processing teams that are assigned
• Collaborate with other Teams as directed that are newly contracted and need to be implemented
• Manage claims inventory to minimize claims turnaround times and ensure contractual SLAs are met
• Drive continuous improvement efforts to improve claims quality and efficiency
• Resolve processing/system issues within assigned department and across all IPAs
• Prioritize work volumes on a daily basis
• Oversee status of production in assigned department to ensure production and quality goals are being met
• Analyze impact of new implementations on assigned department and reallocate staff duties as necessary
• Onboard a large IPA that has global risk to ensure a successful implementation addressing and working with run out for the group, ensure accuracy, timeliness and meeting all regulatory requirements for a smooth transition
• Training off-shore staff to take on a large IPA that is completely new to the organization and ensuring that there are no issues of non-compliance inaccuracies or problems that are brought to the attention of Astrana-This is a huge lift considering the volume of membership, claims run-out responsibility and ensuring there is no lapse in their claims adjudications and payment processes moving forward
• Utilize claims management systems to provide reports and analysis to management on a regular basis
• Develop team members to ensure accountability for achievement of departmental goals and objectives
• Update and facilitate implementation of process and workflow modifications to improve operational efficiency
• Educate and train claims employees on the overall claims process and best practices for successful outcomes
• Address claim inquiries and claim payments by sensitive providers and members
• JOC meetings-attendance and corrective action response when required
• System updates maintaining the integrity of the Claims Payment Database; working inter-departmentally with other managers
• Off-site Seminars IE: E-Z Cap and HMO Regulatory training.
• High level grievances or claim reconsideration request for reimbursable claim reviews as needed
• Evaluate trends in compliance findings to determine root cause and work with Director on remediations such as IDNs, EOBs, and all other findings that need to be addressed with the claims teams or Senior Leadership
• Address non-compliance to Departmental standards with the examiners to include disciplinary actions, PIPs, Training plans and coaching
• Job Descriptions
• format a standardized Claim Department Organizational Chart outlining performance responsibilities and requirements for each position
• Performance evaluation
• monitors track and documents the annual performance evaluation of each Claim Department staff
• Recruit monitor, and document the attendance, production and work quality of Claim Department staff to include employee counseling and/or termination in accordance with HRIS Guidelines
• Staff analysis and growth potential
• Maintain open and effective channels of communication between staff and management
• Represent DMHC Regulatory and CMS Claims Payment Compliance issues at Management Meetings and with the Executive Board
• Using all tools available ( IE: Industry Communications, Seminars, Internet, Professional Networking) to maintain the most current levels of understanding of trends, occurrences, ideology and law that will affect the operation, compliance and stability of the Claims Department and of Astrana
• Communicate this information timely and effectively to both Claims Department Staff and to Management
• Maintains the strictest confidentially at all times
• Responsible for other miscellaneous assignments as requested by Management

Requirements

• Minimum of a Bachelor's degree (B. A.) from a four-year college or university; or four (4) years current Management or equivalent experience with an MSO or IPA Management
• Full knowledge of DMHC, DHS and CMS Regulations and Guidelines, ICD-10, CPT, RV/RBRVS codes
• Experience with contract law and Division Responsibility matrix interpretation
• Comprehensive knowledge in the AB1455 regulations
• EZCAP experience is a huge plus

Benefits

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr., Monterey Park, CA 91754.
• Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.