MSO Claims Manager
Description:
POSITION SUMMARYThe MSO Claims Manager plays a pivotal role in overseeing the day-to-day operations of the Managed Service Organization (MSO) Claims Department, ensuring compliance with CMS, Medicare/Medi-Cal, state, federal, and other regulatory requirements.
As the head of the Claims Department, the Claims Manager will take the lead in training and mentoring Claims employees and addressing various Claims MSO operational requirements.
This position involves managing Claims Examiners and includes responsibilities such as creating, maintaining, and updating Claims policies and procedures, as well as optimizing overall claims operations, identifying, and resolving any gaps, and reporting data needed for Health Plan Audits and any other data requested by internal/external stakeholders.
This role requires the ability to quickly adapt and understand a new database system, QuickCap, and the capacity to work independently while contributing effectively to a team environment.
The successful candidate will demonstrate a strong proficiency in establishing key performance indicators (KPIs) and managing and maintaining accurate data within the database system.
THE SPECS.
Exempt Full-Time Hybrid:
remote and in-office Management Level Benefits-Eligible:
PTO, PSL, Holidays, Medical, Dental, Vision, Etc.
Salary:
90k - 110k, depending on experience.
MAJOR DUTIES AND RESPONSIBILITIES o Oversee Claims Department and Claims Examiner by being proactive and involved in the department, which include mentoring, training, maintaining day-to-day operations and employees.
o Recruit, train and supervise Claims staff, being involved in any areas that employees may need assistance or troubleshooting, and/or covering areas that need more focus.
o Coordinate, monitor, and maintain daily claims operations, overseeing policies and procedures are upheld and/or updated accordingly to promote efficiency.
o Conduct daily audits following Claims Department Policies and Procedures and offer support and training as required.
o Responsible for putting together data reports and any reporting data metrics for Health Plan audits and/or requested by any internal/external stakeholders.
o Compliance with CMS, DMHC, MediCare/Medi-Cal, state, and federal regulatory guidelines.
o Involvement in direct audit preparations, review risk areas, and ability to present findings to senior management and/or other internal/external stakeholders as needed.
o Perform, process, and assist in processing facility claims and other claim payments according to department policies and procedures.
o Ability to manage or put together presentations or information on claims submission, new claims programs, and billing guidelines.
o Quickly learn and adapt to organizational culture, practices, and procedures of MSO environment.
o Identify KPIs of the department to effectively manage and maintain data of Claims Department.
o Meet Claims Processing Turn-Around Time (TAT) and that claims processing TAT meets specified goals and compliance.
o Monitor and troubleshoot any Medicare Claim payments, and the ability to handle or delegate responses accordingly, as needed.
o Analyze EOBs, adjust claims according to processing criteria, and perform pre-check run audits on check run schedules.
o Serve as the subject matter expert, representing Claims Department at any audit and/or interdepartmental meetings.
o Act as a resource for other departments on claims issues, participating in meetings and maintaining a fair work environment, while executing additional duties assigned by management.
o Provide backup supporting claim processing as needed.
o Schedule employee meetings accordingly to address any program/processing changes and training issues.
o Conduct daily audits following Claims Department Policies and Procedures and offer support and training as required.
o Generate comprehensive reports from audit findings, identify trends, and implement strategies to enhance business processes and maintain quality standards.
o Lead appeals to insurance carriers, monitor accounts for accurate fee postings to optimize office collections while minimizing adjustments.
o Respond and justify appeals as to why claims, services, or treatment should be paid.
o Communicate issues and suggestions for process improvements and resolve claims in compliance with CMS guidelines and Company Policies.
o Utilize and resolve claims based on CCI edit report to comply with CMS guidelines.
o Conduct internal reviews to ensure compliance with regulatory and contractual standards in the claims system.
o To contribute to a fair and positive work environment by treating peers, superiors, subordinates, clients, and vendors with professionalism and respect.
o Assist development of standardized audit procedures for recovery opportunities in collaboration with relevant departments.
o Foster a culture of teamwork and productive relationships to facilitate cohesive and efficient operations throughout the organization.
o Effectively communicate audit discoveries and propose solutions across all organizational levels.
o Performs other duties as assigned by management.
IMS offers competitive compensation depending on experience.
We are an equal opportunity employer and seek diversity in our workforce.
IMS is also an E-Verify Employer.
To learn more about E-Verify and your rights and responsibilities, please visit:
https:
//www.
e-verify.
gov/employees/employee-rights-and-responsibilities.
Requirements:
REQUIREMENTS:
Must have experience in Health Plan, Managed Service Organization (MSO), and/or Independent Physician Associations (IPAs) Claims processing, including experience processing facility claims.
Management/supervisor experience specifically in Claims Department.
Adherence with CMS, Medicare/Medi-Cal, state, federal, and other regulatory requirements.
Experience in handling health plan audits and necessary reporting health plans needs.
Extremely strong communication and understanding of MSO culture, practices, and procedures.
Ability to identify KPIs to manage, process, and maintain Claims Department team and specified departmental goals and compliance.
Experience in establishing policies and procedures, and/or advisement on improvements of policies and procedures.
Not afraid to jump in and support team in daily operational duties; lead by example.
Ability to analyze EOBs and adjust claims according to criteria.
Ability to work independently but also in a team environment, by providing support, guidance, and training to Claims Team.
Please note that the duties and responsibilities outlined above are summarized and may not encompass all tasks associated with the position.
The nature of the role may require adaptation to changing circumstances and additional responsibilities not explicitly mentioned here.
The organization reserves the right to modify, interpret, or supplement the job duties as needed.
Compensation details:
90000-110000 Yearly SalaryPI1722b458cce9-25448-33591528 Recommended Skills Auditing Billing Business Processes Coaching And Mentoring Content Management Curiosity Apply to this job.
Think you're the perfect candidate? Apply on company site $('.
external-apply-email-saved').
on('click', function (event) window.
ExternalApply = window.
open('/interstitial?jobdid=j3w6kh74003pdhr1xp1', 'ExternalApply-j3w6kh74003pdhr1xp1'); ); Estimated Salary: $20 to $28 per hour based on qualifications.
POSITION SUMMARYThe MSO Claims Manager plays a pivotal role in overseeing the day-to-day operations of the Managed Service Organization (MSO) Claims Department, ensuring compliance with CMS, Medicare/Medi-Cal, state, federal, and other regulatory requirements.
As the head of the Claims Department, the Claims Manager will take the lead in training and mentoring Claims employees and addressing various Claims MSO operational requirements.
This position involves managing Claims Examiners and includes responsibilities such as creating, maintaining, and updating Claims policies and procedures, as well as optimizing overall claims operations, identifying, and resolving any gaps, and reporting data needed for Health Plan Audits and any other data requested by internal/external stakeholders.
This role requires the ability to quickly adapt and understand a new database system, QuickCap, and the capacity to work independently while contributing effectively to a team environment.
The successful candidate will demonstrate a strong proficiency in establishing key performance indicators (KPIs) and managing and maintaining accurate data within the database system.
THE SPECS.
Exempt Full-Time Hybrid:
remote and in-office Management Level Benefits-Eligible:
PTO, PSL, Holidays, Medical, Dental, Vision, Etc.
Salary:
90k - 110k, depending on experience.
MAJOR DUTIES AND RESPONSIBILITIES o Oversee Claims Department and Claims Examiner by being proactive and involved in the department, which include mentoring, training, maintaining day-to-day operations and employees.
o Recruit, train and supervise Claims staff, being involved in any areas that employees may need assistance or troubleshooting, and/or covering areas that need more focus.
o Coordinate, monitor, and maintain daily claims operations, overseeing policies and procedures are upheld and/or updated accordingly to promote efficiency.
o Conduct daily audits following Claims Department Policies and Procedures and offer support and training as required.
o Responsible for putting together data reports and any reporting data metrics for Health Plan audits and/or requested by any internal/external stakeholders.
o Compliance with CMS, DMHC, MediCare/Medi-Cal, state, and federal regulatory guidelines.
o Involvement in direct audit preparations, review risk areas, and ability to present findings to senior management and/or other internal/external stakeholders as needed.
o Perform, process, and assist in processing facility claims and other claim payments according to department policies and procedures.
o Ability to manage or put together presentations or information on claims submission, new claims programs, and billing guidelines.
o Quickly learn and adapt to organizational culture, practices, and procedures of MSO environment.
o Identify KPIs of the department to effectively manage and maintain data of Claims Department.
o Meet Claims Processing Turn-Around Time (TAT) and that claims processing TAT meets specified goals and compliance.
o Monitor and troubleshoot any Medicare Claim payments, and the ability to handle or delegate responses accordingly, as needed.
o Analyze EOBs, adjust claims according to processing criteria, and perform pre-check run audits on check run schedules.
o Serve as the subject matter expert, representing Claims Department at any audit and/or interdepartmental meetings.
o Act as a resource for other departments on claims issues, participating in meetings and maintaining a fair work environment, while executing additional duties assigned by management.
o Provide backup supporting claim processing as needed.
o Schedule employee meetings accordingly to address any program/processing changes and training issues.
o Conduct daily audits following Claims Department Policies and Procedures and offer support and training as required.
o Generate comprehensive reports from audit findings, identify trends, and implement strategies to enhance business processes and maintain quality standards.
o Lead appeals to insurance carriers, monitor accounts for accurate fee postings to optimize office collections while minimizing adjustments.
o Respond and justify appeals as to why claims, services, or treatment should be paid.
o Communicate issues and suggestions for process improvements and resolve claims in compliance with CMS guidelines and Company Policies.
o Utilize and resolve claims based on CCI edit report to comply with CMS guidelines.
o Conduct internal reviews to ensure compliance with regulatory and contractual standards in the claims system.
o To contribute to a fair and positive work environment by treating peers, superiors, subordinates, clients, and vendors with professionalism and respect.
o Assist development of standardized audit procedures for recovery opportunities in collaboration with relevant departments.
o Foster a culture of teamwork and productive relationships to facilitate cohesive and efficient operations throughout the organization.
o Effectively communicate audit discoveries and propose solutions across all organizational levels.
o Performs other duties as assigned by management.
IMS offers competitive compensation depending on experience.
We are an equal opportunity employer and seek diversity in our workforce.
IMS is also an E-Verify Employer.
To learn more about E-Verify and your rights and responsibilities, please visit:
https:
//www.
e-verify.
gov/employees/employee-rights-and-responsibilities.
Requirements:
REQUIREMENTS:
Must have experience in Health Plan, Managed Service Organization (MSO), and/or Independent Physician Associations (IPAs) Claims processing, including experience processing facility claims.
Management/supervisor experience specifically in Claims Department.
Adherence with CMS, Medicare/Medi-Cal, state, federal, and other regulatory requirements.
Experience in handling health plan audits and necessary reporting health plans needs.
Extremely strong communication and understanding of MSO culture, practices, and procedures.
Ability to identify KPIs to manage, process, and maintain Claims Department team and specified departmental goals and compliance.
Experience in establishing policies and procedures, and/or advisement on improvements of policies and procedures.
Not afraid to jump in and support team in daily operational duties; lead by example.
Ability to analyze EOBs and adjust claims according to criteria.
Ability to work independently but also in a team environment, by providing support, guidance, and training to Claims Team.
Please note that the duties and responsibilities outlined above are summarized and may not encompass all tasks associated with the position.
The nature of the role may require adaptation to changing circumstances and additional responsibilities not explicitly mentioned here.
The organization reserves the right to modify, interpret, or supplement the job duties as needed.
Compensation details:
90000-110000 Yearly SalaryPI1722b458cce9-25448-33591528 Recommended Skills Auditing Billing Business Processes Coaching And Mentoring Content Management Curiosity Apply to this job.
Think you're the perfect candidate? Apply on company site $('.
external-apply-email-saved').
on('click', function (event) window.
ExternalApply = window.
open('/interstitial?jobdid=j3w6kh74003pdhr1xp1', 'ExternalApply-j3w6kh74003pdhr1xp1'); ); Estimated Salary: $20 to $28 per hour based on qualifications.
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