American Health Quality Association
Sr. Mgr Claim Quality Support
American Health Quality Association, Houston, Texas, United States, 77246
JOB SUMMARY:The Sr. Manager, Claims Quality Support oversees the timely resolution of all post claims adjudication tasks including, but not limited to, priority reconsideration requests, payment disputes, and claim appeals. This position leads all in-house Coordination of Benefits and Recoupment efforts and works in tangent with Configuration Support on recoupment opportunities identified. This position works to address iterations of training needs as part of continuous quality improvement support for claims staff. This position ensures the success of post payment tasks by adopting a culture of excellence. This leader identifies service level trends and conveys findings to applicable unit leaders within Community Health Choice.
MINIMUM QUALIFICATIONS:Education/Specialized Training/Licensure:Bachelor's Degree or 4 years claims experience in lieu of degree required.Work Experience (Years and Area):Seven (7) years of claims with a health plan or Third Party Administrator.Experience in a production environment utilizing technology platforms and support related to system upgrades and testing relative to claims applications and tools.Management Experience (Years and Area):Five (5) years managing claims appeals, disputes, adjustments or healthcare compliance for a health plan or third party administrator with multidisciplinary teams.Software Operated:Microsoft Office (Word, Excel, Outlook);Claims Applications;QNXT or EPIC Systems a plus.Other Requirements:Experienced in policy interpretation related to appropriateness and accuracy of payment disputes, appeals, reconsiderations and industry practices.Multi-tasker with excellent analytical and leadership skills with the demonstrated ability to achieve key departmental objectives.Broad range of experience including Commercial, Medicare and Medicaid lines of business.Familiar with various payment methodologies and contract language in an effort to assess provider billing appropriateness and claim billing practices looking for potential fraud, waste, and abuse.SPECIAL REQUIREMENTS:Communication Skills:Above Average Verbal (Heavy Public Contact)Exceptional Verbal (e.g., Public Speaking)Writing /Composing: Correspondence / ReportsOther Skills:Analytical, Medical Terminology, Research, Statistical, MS ExcelAdvanced Education:Bachelor's Degree Major: PreferredRESPONSIBLE TO: DirectorEMPLOYEE SUPERVISED: Professional/Staff
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MINIMUM QUALIFICATIONS:Education/Specialized Training/Licensure:Bachelor's Degree or 4 years claims experience in lieu of degree required.Work Experience (Years and Area):Seven (7) years of claims with a health plan or Third Party Administrator.Experience in a production environment utilizing technology platforms and support related to system upgrades and testing relative to claims applications and tools.Management Experience (Years and Area):Five (5) years managing claims appeals, disputes, adjustments or healthcare compliance for a health plan or third party administrator with multidisciplinary teams.Software Operated:Microsoft Office (Word, Excel, Outlook);Claims Applications;QNXT or EPIC Systems a plus.Other Requirements:Experienced in policy interpretation related to appropriateness and accuracy of payment disputes, appeals, reconsiderations and industry practices.Multi-tasker with excellent analytical and leadership skills with the demonstrated ability to achieve key departmental objectives.Broad range of experience including Commercial, Medicare and Medicaid lines of business.Familiar with various payment methodologies and contract language in an effort to assess provider billing appropriateness and claim billing practices looking for potential fraud, waste, and abuse.SPECIAL REQUIREMENTS:Communication Skills:Above Average Verbal (Heavy Public Contact)Exceptional Verbal (e.g., Public Speaking)Writing /Composing: Correspondence / ReportsOther Skills:Analytical, Medical Terminology, Research, Statistical, MS ExcelAdvanced Education:Bachelor's Degree Major: PreferredRESPONSIBLE TO: DirectorEMPLOYEE SUPERVISED: Professional/Staff
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