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Oversees and directs the management of the claims function to include review and approval of claims. Directs the implementation and ongoing maintenance of claims handling systems, policies, and procedures. Typically requires a college degree and five or more years of claims management experience.: Monitors departmental operations to ensure compliance with regulatory agencies as well as contractual obligations. Performs regular data analysis of claims payment reports to identify variances so that areas of focus may be identified and resources may be appropriately deployed. Provides support on complex claims issues. Prepares and manages the departmental budget and manages expenses. Hires, develops, and motivates a qualified claims processing staff.

Medical Claims Review Manager

Manages the medical claims review staff to ensure process improvement and quality in claims review. This position typically requires a Bachelor’s degree with five years of medical review experience. This position may require a nursing degree.: Manages the medical claims review staff to ensure process improvement and quality in claims review. Translates benefit plan language (Summary Plan Descriptions) into standard review program procedures. Interfaces with clients to conduct/manage random sample reviews to determine medical claims processing accuracy and timeliness. Works with clients to coordinate operational reviews to assess administrative processes and controls. Reviews company claims, eligibility, provider, and medical management systems to identify issues affecting quality and productivity. Documents findings and write follow-up reports. Provides planning, organizing and budgeting for the department. Develops, administers and reports service quality indicators for each team under supervision. Recommends and implements innovative strategies to retain members, contain medical costs and improve efficiency. Hires, trains, coaches, counsels and evaluates performance of direct reports. This position typically requires a Bachelor’s degree with five years of medical review experience. This position may require a nursing degree.

Claims Quality Audit Manager

Supervises and facilitates the coordination and scheduling of all external claims audits conducted by customers, audit firms, external vendors, and regulators. Assists in the preparation of audits and management of the audit process. : Notifies appropriate parties of the audit and schedules entrance and exit conferences. Develops tools to assist staff in effectively coordinating audits and holds staff meetings as needed. Reviews customer contracts for audit rights, and prepares necessary audit confidentiality agreements and Par Plan addendum agreements. Supervises the obtaining and reviewing of claim samples and documentation. Ensure all HIPAA requirements applicable to the job are met. Directs and oversees analysis of requested data in order to minimize organization's risks. Ensures data integrity. Assures that auditors have a positive experience. Reviews findings and responses for adequacy and appropriateness. Reviews draft and final audit reports from auditors. Prepares responses to report findings. May travel to other claims audit locations as needed.

Claims Quality Audit Director

Directs the Claims Quality Audit Department and provides managerial oversight to employees engaged in claims auditing and training. Approves department policies, practices, and procedures to ensure identification of claims processing errors. Provides planning, organizing, and budgeting for the department. Typically requires a college degree in a related field and an in-depth understanding of claims auditing.: Provides oversight of departmental training and auditing activities. Monitors departmental operations to ensure compliance with regulatory agencies and contractual obligations. Develops strategic initiatives and transforms initiatives into action plans. Hires, trains, and motivates a qualified management staff. Oversees the development of training programs that are targeted toward error reduction and decision quality in claims processing. Analyzes audit and training reports to determine department effectiveness.

Claims Quality Audit Supervisor

Supervises employees engaged in claims auditing and training. Implements claim auditing department policies, practices, and procedures to ensure identification of claims processing errors. Typically requires prior experience as a Claims Processor or Adjudicator and an in-depth understanding of claims auditing.: Supervises auditing activities by monitoring weekly backlogs, distributing audit assignments based on work loads, and reviewing and responding to audit inquiries. Responds to error rebuttals from Claims Processors or Adjudicators. Assists in hiring, training, coaching, and evaluating performance of assigned staff. Contributes to the development of training programs that are targeted toward error reduction and decision quality in claims processing. Monitors training programs to evaluate effectiveness.

Medicare Claims Supervisor

Supervises the Medicare claims processing staff to ensure accurate and timely adjudication of claims. This position typically requires four years of experience in claims processing or auditing.: Supervises the Medicare claims processing staff to ensure accurate and timely adjudication of claims. Provides training and development, communicates policies and procedures, and monitors work production quantity and quality. Reviews and resolves complex claims issues that cannot be resolved by subordinates and releases high dollar claims as needed. Ensures that all claims are processed according to the terms of the plan contract and applicable policies, procedures and department guidelines. Oversees documentation of claims and billing forms to support claim decision, payment or denial. In addition to supervisory skills, must have knowledge of discipline equal to or exceeding that of direct reports. Typically supervises more than 8 Claims Adjudicators. Tracks and monitors claims volume and age of inventory. Submits statement of claim liabilities to accounting for review. Interprets company policy to employees and enforces company policy and practices. Reviews and analyzes processes, procedures and workflows to identify opportunities for process improvement and efficiency. Prepares regular periodic reports and reviews/monitors system reports to ensure adherence to corporate and regulatory standards within established guidelines. Monitors the work flow process to ensure that work is distributed appropriately. This position typically requires four years of experience in claims processing or auditing. May be called upon to manage unit(s) in the absence of the Claims Manager. May recruit, hire, train staff, evaluate employee performance, and recommend or initiate promotions, transfers, and disciplinary action.

Claims Supervisor

Supervises and coordinates activities of workers engaged in examining insurance claims for payment in claims division of insurance company. Ensures all claims eligible or ineligible for payment conform to quality, production standards and specifications. A bachelor's degree with four years of claims examining/auditing experience may be required to fulfill the requirements of this position.: Ensures evaluation of all claims through determination of types and amounts of benefit payable. Ensures/oversees documenting of provider claims/billing forms to support payment/decisions. Ensures claims processing is consistent with applicable policies, procedures, and department guidelines. Supervises maintenance of claims records. Reviews appeals and complaints that Examiners are unable to resolve. Analyzes and approves insurance claims. Conducts personal interviews with claimants to explain procedure for filing claims. Submits statement of claim liabilities to actuarial department for review. Informs departmental supervisors on claims status. Interprets company policy to employees and enforces company policy and practices. Reviews and analyzes processes, procedures, and workflows to identify opportunities for process improvement and efficiency. Prepares regular periodic reports, and reviews/monitors system reports to ensure adherence to corporate and regulatory standards within established guidelines. May participate in the specialized training and handling of complex claim situations and projects requiring advanced claim knowledge and experience, as delegated by Claims Manager and/or Director. May recruit, hire, train staff, evaluate employee performance, and recommend or initiate promotions, transfers, and disciplinary action.

Medical Claims Review Nurse

Resolves, audits, and processes claims for clinically related issues to ensure accuracy of claims payment, supporting the Claims Administration Department. Maintains contact with community hospitals and providers, reviewing, processing, and auditing claims for payment and appropriateness of charges and pursues adjustments as warranted. Typically requires licensure as a Registered Nurse and at least one year of experience in utilization review or a managed care setting.: Screens, audits, and processes claims of specific criteria for appropriate payment. Establishes effective ongoing relationships with community hospitals and providers. Participates in educational, provider relations, and contracting meetings with providers to address medical claims payment issues. Visits the providers as necessary to compare billed charges to the medical record. Provides support to the Accounting Department in determining financial liability for out-of-plan medical services. Performs special projects, reconciliations, research, and analysis relating to the utilization and cost of medical services. Works closely with various departments to coordinate the flow of information involving payment of medical bills and analyses of financial liability. Ensures compliance with contractual obligations on claims payments. Documents findings and writes follow-up reports. Recommends and implements innovative strategies to retain members, contain medical costs, and improve efficiency.

Claims Auditor

Conducts claims audits to ensure accuracy of claims determinations. Manages and coordinates the reporting, review, and maintenance of data for use in supporting audit functions. : Performs claims audits based on audit program and specified target audits as assigned. Documents audit findings accurately. Assures quality of claim determinations and ensures compliance with regulations and plan requirements. Researches, analyzes, and understands claims processing and payment regulations. Understands and applies standard pricing methodologies for claims. Identifies underpayments/overpayments and generates reports to quantify amounts detected through audit process. Communicates errors to Production Manager or Supervisor and trends errors for corrective actions. Identifies and develops potential areas for claim audits. Evaluates audit initiatives and identifies enhancements to the audit processes and procedures as needed. Determines whether to accept, reject, or request additional information based on policies and procedures.

Disability Work Compensation Claims Specialist

Reviews, analyzes, investigates, makes liability decisions and approves the release of benefit payments up to authorized levels on initial, continued and reopened claims.: Independently reviews simple to complex claims for adjudication purposes. Evaluates new and ongoing claims to determine liability according to contract provisions, medical evidence, and vocational evidence and duration contract guidelines. Performs periodic follow-up to determine continuing existence of a disabling condition. Analyzes documentation and summarizes data gathered from a variety of sources. Responds to telephone and written inquiries from claimants, attorneys, physicians and policy holders. Updates and maintains accurate records. This position typically requires knowledge of case law and state worker’s compensation laws. A minimum of three years of claims adjudication experience is typically required.

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