Our Mission: Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.
Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.
Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!
Position Purpose: The Claims Manager upholds and administers claims processing, oversees the daily operations of the Claims Department and ensures adherence to Health Choice policy and procedure and contractual and regulatory guidelines for claims administration. Oversight of day-to-day activities of Claims processing, including, provider claim issues, including PDM (provider data maintenance) management and setup; benefit set-up, and auto-adjudication; Position is responsible for oversight of Claims Clerk duties, which may include, but not be limited to, specific pended claims reports, RPA (Robotic processing automation) processing, scanning vendor rejections.
* Oversee daily claims activities to ensure regulatory claims compliance
* Reviews claim adjudication logic for appropriateness
* Responsible to look for opportunities for automation, including, but may not be limited to claims system auto adjudication and robotic processing automation (RPA).
* In conjunction with Training & Development, ensure appropriate training materials and training sessions are available for all Claims staff
* Develop and maintain job descriptions for Claims staff, cognizant of the organizational changes and how they may impact Resolutions Center operations
* Recommend to leadership changes to operational structure
* Ensures policies and procedures relevant and updated
* Continually reviews and makes necessary adjustments for claims processor production and quality standards
* Resolve staff issues related to claims operations, inclusive of HR issues and resolution
* Develop and maintain working relationship with other Departmental Managers
* Works with IS staff in order to ensure appropriate system modifications and setup, inclusive of updated regulatory fee schedules
* Responsible for regulatory reporting, audits and operational reviews
Education / Experience / Other Requirements
* Bachelor’s Degree Preferred
Years of Experience:
* 3 years of managed care experience
* 3 years claims processing or related claims experience
* 3 years team leadership
* Claims processing, inclusive of 1500 and UB
* Medical terminology
* Computer, inclusive of Microsoft Office and proprietary claims systems
* Effective communication, verbal and written
* Management and organizational skills
* Medicaid, Medicare, AHCCCCS policies and procedures
* Ability to think analytically and make independent decisions
* Ability to lead a team