Responsibilities:
The Claims Quality Assurance Manager is responsible for ensuring the integrity of all data created and updated by the Claims staff. Direct, oversee and coordinate with other IEHP departments and IEHP providers, claims activities and claims staff to achieve compliance with regulatory and departmental guidelines.
Ensure all claims activities are completed accurately and timely. Assist the Director of Claims in the implementation and monitoring of the unit productivity and standards program. Develop effective and efficient methods for accurate data entry and adjudication.
Supervision and training of Claims personnel including establishing and monitoring performance standards and completing formal evaluations.
Experience:
3 years claims processing experience, at least 1 of which was in a supervisory capacity. 3 years experience in a managed care environment. 1 year processing UB92s preferred. Experience in benefit and financial matrix interpretation. Use of the Medi-Cal fee schedule.
Extensive knowledge of ICD9, CPT and Revenue Codes. Solid understanding of the HCFA and DHS rules and regulations governing claims adjudication practices and procedures desired. Principles and techniques of supervision and training. Analytical skills with emphasis on time management, data base maintenance, spreadsheet manipulation, and problem solving. Strong writing, organizational, project management, and communication skills proficiency required. Must have a high degree of patience, excellent interpersonal/communication skills.
Bachelor's degree preferred, or equivalent work experience in a Managed Care or Health Care environment.
IEHP, Inland Empire Health Plan, A Public Entity, is committed to delivering high quality health care simpler... simpler for Members AND Providers. High quality, simpler health care makes for healthier and happier families and communities.
