Job Summary
- Company
- Bravo Health
- Location
- Baltimore, MD 21201
- Industries
- Insurance
- Healthcare Services
- Job Type
- Full Time
- Employee
- Career Level
- Manager (Manager/Supervisor of Staff)
- Job Reference Code
- 139
Manager, Claims, Quality and Audit
About the Job
Position Summary:
Under the direction of the Director, the Manager of Claims Quality and Audit provides oversight to the teams. The duties include responsibility for the internal Claims quality function relating to the payment and/or denial of claims. This manager is also be responsible for coordination and development of Claims training tools done in conjunction with the Claims Production staff. The team will also interpret the application of benefits, along with authorization requirements and develop the reference materials for use by the Claims processing staff.
Essential Duties and Responsibilities:
- Development and management of a Claims Quality process and the direct oversight and supervision of the Claims Quality team.
- Manage and develop team: monitor workload, ensure job proficiency, develop career goals by monitoring and evaluating individual staff performance and giving appropriate feedback, identify training and development needs and support training coordination of incorporating trend analysis results, lead and motivate staff to achieve excellent customer service standards, retain staff and create a good work environment, recognize accomplishments, and serve as role model and coach by providing feedback to improve performance and executing discipline as needed.
- Develop compliant audit and Quality identification and collection process including the design of audit tools, establishing collection practices and processes to achieve the financial goals established by the organization. This will include the design and development of audit reports and other data mining activities as well as the development of reporting tools used for the compilation of actual financial results.
- Manage Vendor relationships of external Quality and audit firms/vendors engaged including coordination to avoid duplication, accounting of recoveries and monthly reporting responsibilities.
- Develop processes, workflow, oversight tools and controls to ensure special contractual limitations are adhered to in regards to the Quality process.
- Evaluate and troubleshoot system configuration issues relating to overpayments recurring on a routine basis to turn recoveries into avoidance. Coordinate all proposed changes with EzCap and QNXT staff.
Knowledge, Skills, Abilities Required:
- Working knowledge of Medicare reimbursement methodologies including FFS, DRG, CMG, and HHRGs.
- Advanced problem solving and technical skills associated with the claims processing industry (including CPT, HCPCS, and ICD-9 coding)
- Demonstrated mathematical, advanced problem solving skills, data entry, PS, stress management, and organizational skills.
- Strong oral/written communication skills, and demonstrated leadership skills with an emphasis on team building and issue resolution, counsel staff to effectively resolve work related issues, thus maintaining an effective, efficient and pleasant work place.
- Working knowledge of systems configuration including Provider Contract interpretation.
Qualifications:
- Bachelor’s degree or equivalent work experience.
- 3-7 years work experience in claims processing, claim audit, claims resolution and/or Quality in a health care setting (prefer Medicare Carrier experience) with at least 2 years of Quality experience required.
- Preferred at least 3 years of successful supervisory/managerial experience.
Computer Skills:
Excellent knowledge of Excel, Access and working knowledge of Crystal reporting.
See Job Description
