Manager,Claims

DaVita Medical Group - El Segundo, CA3.3

Full-time
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OVERVIEW:
Responsible for overseeing the timely adjudication of all insurance claims, claim follow-ups and adjustments. Establishes departmental procedures and standards to ensure provider and regional satisfaction.

ESSENTIAL FUNCTIONS:
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Works closely with the Claims management team, regional management team and other departments to resolve specific claims issues and ensures compliance with all health plan requirements and industry regulations.
Attends meetings to provide input (i.e. reports trends and assesses the root of the problem), obtains information and disseminates results of these meetings appropriately.
Updates and establishes new guidelines and procedures for automation processes using appropriate reference materials.
Manages the identification, reporting and coordination of benefits / third party liability cases.
Recovers overpayments and underpayments.
Reviews provider’s payment appeals, performs negotiation with provider and initiates resolution disputes.
Assists with the negotiation of provider settlements.
Participates in health plan audits to ensure that all necessary documentation is provided for health plan audits and discusses HCP’s outcomes.
Oversees the Retro Review process and works closely with Care Management to align claims payment guidelines for claims authorization.
Provides input to CAP (corrective action plan) as needed.
Applies appropriate reference tools (e.g. Prospective Review List, Preferred Provider List, CPT and ICD-9 coding books, HCP and IMCS policies and procedures manual).
Maintains and updates the department policies and procedures manual as required.
Devises standard forms and letters for department use.
Participates in the development and implementation of strategic workgroups (internal and external).
Participates in the continuous maintenance and quality improvement of IMCS core business system.
Participates in the preparation process for the annual budget and monitoring of monthly budget year to date.
Provides direction, guidance, and training to department supervisors and staff.
Assists in the development of departmental and individual goals.
Ensures appropriate management of department staff including timely completion of performance appraisals and corrective counseling when necessary.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.

EDUCATION:
One or two years of post-high school education or a degree from a two-year college.

EXPERIENCE:
Minimum:
Over 7 years and up to and including 10 years of experience working in a healthcare claims department.

KNOWLEDGE, SKILLS, ABILITIES:
Computer literate.
Proficient in Microsoft Office applications.
Advanced knowledge of medical terminology, ICD-9 and CPT coding.
Proven problem-solving and decision-making skills.
Strong leadership skills.
Excellent verbal and written communication skills.
Excellent organizational and time-management skills.
Detail-oriented
Excellent customer service skills.
Ability to work independently.
Valid California driver’s license.
What's the first thing that happens when one of the leading independent medical groups in the country comes together with a global leader in health care? Opportunity. With DaVita Medical Group, HealthCare Partners, The Everett Clinic, Northwest Physicians Network, MountainView Medical Group and Magan Medical Clinic joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. We're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(SM)

Careers with OptumCare. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. OptumCare, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)

Diversity creates a healthier atmosphere: OptumCare and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. OptumCare and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.