Medical Claims Manager - Onsite - EDI Staffing
Coral Gables, FL 33134
About the Job
Our client has an exciting opportunity for a Medical Claims Manager to lead their Claims Department. This is an onsite position, based in Coral Gables, FL.
The Claims Manager oversees the claims and repricing departments, ensuring efficient and accurate processing of medical claims. This role involves supervising daily operations, monitoring timelines, and maintaining client communication to meet deadlines and provide updates. The manager identifies the best networks for claim processing to maximize client savings and performs quality assessments to minimize errors.
In addition, the manager coordinates with other departments to ensure process adherence, trains staff on claims handling, and implements procedures for new business lines. Acting as the key liaison between clients and internal teams, the manager provides regular updates, resolves claims issues, and ensures processes align with company goals. This role requires strong leadership, attention to detail, and a commitment to improving claims processing efficiency while maintaining client satisfaction.
Duties & Responsibilities:
The Claims Manager oversees the claims and repricing departments, ensuring efficient and accurate processing of medical claims. This role involves supervising daily operations, monitoring timelines, and maintaining client communication to meet deadlines and provide updates. The manager identifies the best networks for claim processing to maximize client savings and performs quality assessments to minimize errors.
In addition, the manager coordinates with other departments to ensure process adherence, trains staff on claims handling, and implements procedures for new business lines. Acting as the key liaison between clients and internal teams, the manager provides regular updates, resolves claims issues, and ensures processes align with company goals. This role requires strong leadership, attention to detail, and a commitment to improving claims processing efficiency while maintaining client satisfaction.
Duties & Responsibilities:
- Supervise the claims and repricing departments to ensure proper workflow is conducted.
- Monitor timelines and constantly communicate with clients to follow up on claims handling.
- Responsible for searching PPO networks and direct contracts database to determine the appropriate network that a claim should be processed through to secure the greatest savings to customers.
- Meets deadlines promised to clients for claims processing.
- Review and perform quality assessments of work being released to clients to ensure claims processing errors are kept at a minimum.
- Identify claims that should be audited by the Medical Team when the total charges exceed the pre-established criteria.
- Coordinate and liaise with other department Supervisors to ensure the operational process is followed.
- Identifies claims where little or no discount is available so that the Company may negotiation those claims.
- Implement new procedures for new lines of business.
- Train and cross-train all staff member with Claims Handling Process.
- Provide clients with daily, weekly and or monthly updates on Claims
- Review all rejected claims from Healthcare
- Prepare Eligibility file for Healthcare
- Collaborate and communicate with other departments on claims issues.
- Train new staff, also cross train existing staff
Required Experiences:
- Supervisory Experience in Claims Processing:
- Proven experience leading and managing a claims processing team, including the ability to ensure proper workflow and operational efficiency.
- Client Relationship Management:
- Experience in maintaining consistent communication with clients, monitoring timelines, and ensuring timely follow-up on claims handling and deadlines.
- Knowledge of PPO Networks and Direct Contracts:
- Familiarity with searching and utilizing PPO networks and direct contracts databases to determine the most appropriate network for claim processing to maximize savings.
- Quality Assurance in Claims Processing:
- Experience in reviewing and performing quality assessments on claims to minimize errors and ensure accuracy before releasing work to clients.
- Experience in Medical Auditing:
- Ability to identify claims that require auditing based on pre-established criteria, particularly when charges exceed certain thresholds.
- Operational Coordination:
- Experience working closely with other department supervisors to ensure seamless adherence to operational processes and procedures.
- Claims Negotiation:
- Proven ability to identify claims with minimal discounts and effectively negotiate better terms to secure savings for the company.
- Process Improvement and Implementation:
- Experience in implementing new procedures, particularly for new lines of business, and driving continuous improvement in claims processing workflows.
- Staff Training and Development:
- Strong background in training and cross-training staff in claims handling processes, including onboarding new employees and developing existing team members.
- Claims Review and Issue Resolution:
- Experience reviewing rejected claims, preparing eligibility files, and collaborating with other departments to resolve claims-related issues.
- Healthcare Industry Knowledge:
- In-depth understanding of healthcare claims processing, including knowledge of eligibility requirements and healthcare provider interactions.
- Excellent health and dental insurance coverage
- Free vision, life and hospital gap insurance
- 12 paid holidays
- Paid Time Off
- 401K with company match up to 4%
- Salary range is commensurate with the experience of the candidate
Source : EDI Staffing