Manager, Claims Adjustments & MCA

Manager, Claims Adjustments & Mass Claim Adjustment

The Manager, Claims Adjustments & Mass Claim Adjustment (MCA) is responsible for providing leadership and direction to employees in the Claim Adjustment department to ensure the goals and standards of the department and CareSource are met. Essential functions include managing staffing and scheduling functions to meet regulatory requirements and service level agreements (SLA's). Oversee orientation and training of new team members and direct day-to-day staff activities to ensure service and performance objectives are achieved. Engage direct reports through consistent performance feedback and development opportunities. Manage and maintain reporting dashboards for inventory and root cause identification. Have a deep understanding of the claim adjudication process to lead and develop team to increase accurate automation of claims. Manage claims adjustment automation through direction and oversight of MCA tool, robot automation tools, and manual adjustments. Research and propose automation advancements; engage appropriate cross functional areas for solution development and implementation. Ensure root cause identification occurs on adjustment ticket to identify and remediate claim system issues. Prioritize tickets, projects, and escalations according to market and strategic needs. Provide oversight of claim adjustment ticketing solution (OnBase, Service Now, SharePoint, Facets, TFS, email). Ensure claim adjustment team members identify, escalate and / or resolve complex or non-routine questions, issues, and problems within SLA timelines and provide direction as needed and / or escalate to senior management as appropriate. Ensure that proper communication and approvals are in place prior to completion of tickets. Manage communications on claim handling to ensure alignment, coordination, and strategic messaging (key areas of focus, key process changes impacting the process). Create consistency with respects to practices and processes for early identification of root cause, adjustment methods, and execution. Collaborate closely with team, leadership, and cross functional teams on utilization of analytics, process automation and improving efficiencies. Identify and facilitate process improvements to improve productivity, accuracy, and data usability. Responsible for understanding industry advancements in claims processing and automation and identifying opportunities to leverage efficiencies for claim adjustments. Collaborate with teams in Claims, Configuration, Claim Edits, Member Benefits, Utilization Management, Health Partnership, and around CareSource to ensure claims are processing appropriately based on the need of the entire claim payment lifecycle. Assist in the development and implementation of departmental policies and procedures. Oversee Claims initiatives such as working with IT and others to automate claims functions and improve front end processes, implement new business including the design, testing and delivery of supporting processes to the business. Actively participate and partner with vendor management and procurement to secure effective and efficient vendor contracts. Perform any other job duties as requested.

Education and Experience : Bachelor's degree in business administration, healthcare a related field or equivalent years of relevant work experience is required. Four (4) years of healthcare claims or operations experience is required. Two (2) years of previous leadership experience is required. FACETS Claims experience required.