Anaheim, California
HEALTHCARE CLAIMS MANAGER - MEDICARE / MEDI-CAL - MSO Job Opening in Anaheim, California - HEALTHCARE CLAIMS MANAGER - MEDICARE / MEDI-CAL - MSO - Anaheim, CA
agilon health Corporate Overview:
agilon health is a healthcare services and technology company aiming to accelerate the conversion to value-based healthcare. The company, with headquarters in Long Beach, California, brings together established value-based healthcare delivery systems, physician risk enabling infrastructure, and proven operating talent from across healthcare. The combination of these capabilities and a unique partnership-centric approach offers providers on a national basis the opportunity to successfully transition to risk-based business models.
agilon health empowers physicians and other providers with the clinical, technological and administrative capabilities to function effectively in a healthcare system undergoing a structural shift to a compensation model based on outcomes, rather than traditional fee-for-service, and to capture the inherent opportunity in bearing global financial risk associated with improving patient outcomes and lowering total cost of care. agilon health, through its value-based delivery systems, has a strong track record operating in multiple capitated markets, currently managing more than 475,000 patients through a network of more than 1,500 primary care physicians and 8,000 specialists. agilon health?s partnership solution includes information and support systems, data analytics and sophisticated medical management infrastructure to support physicians across the risk spectrum, from professional capitation to full capitation.
Manager Claims - Healthcare - Medicare / MediCal - MSO - Position Overview:
The Claims Manager is responsible for the daily operations and performance of Claim Department. This position is responsible for consistent compliance in all aspect of claims operations. The Claims Manager demonstrates effective leadership and management skills. Ensure workload are appropriately distributed and monitored. The Claims Manager is responsible in making sure appropriate training is provided to staff members. Collaborates with other stakeholders in developing process improvements as they relate to claims payment accuracy and timeliness.
Key Responsibilities:
Manages the daily operations of Claims Department. Ensure workload are organized and appropriately distributed. Establishes work standards to promote efficiency and productivity.
Ensures compliance in all areas of operations such as accurate and timely processing of claims
Manages process improvement initiatives which include seeking root cause, developing and implementing appropriate corrective action
Develops and implements policies and procedures and desk level procedures/job aids related to claims operations. Ensures that adequate in-service education is available to staff members
Collaborate with all levels of personnel within the company in developing processes and/or systems to meet company?s and/or regulatory
Serves as the subject matter expert in handling complex claim issues and complaints from internal and external customers
Stays abreast on all regulatory and/or contractual changes, communicates changes to appropriate staff and department
Demonstrates effective management and leadership skills
Participates in recruitment activities which include identifying, interviewing and hiring candidates
Coordinates department?s activities to meet budget and deadlines and resolves conflicting demands
Motivates and manages staff to ensure that performance standards are met or exceeded.
Gives timely and constructive feedback on performance; documents all corrective counseling.
Prepares and conducts fair and objective performance appraisal timely
Conducts departmental staff meetings monthly or more frequently if needed.
Keeps staff apprised of changes in organization and departmental policies.
Acts as a role model in demonstrating the customer service standards of the organization.
Attends administrative meetings as appropriate and contributes ideas for improving efficiency, productivity and customer satisfaction.
Attends all mandatory management education and trainings
Other related duties as assigned.
Relationships:
Reports to: Director, MSO Operations
Qualifications:
High school diploma required; College degree in related field preferred
3-5 years claims management experience in health plan, MSO or IPA/Medical Group setting required
5-7 years Medicare and MediCal claims processing experience in health plan, MSO or IPA/medical group setting required
Working knowledge of different state and federal regulatory requirements related to claims processing which include knowledge of different providers? payment methodologies (capitation, fee for service based on different Medicare/MediCal fee schedules and pricing systems), required
Computer skills to include working knowledge of MS-Office programs (Word, Excel, Power Point, etc.), required
Ability to develop Policies and Procedures and effective training materials and action plans required
Language skills to include interpreting payor and provider contracts and regulatory documents
Working knowledge of medical terminology and claims coding to include CPT, HCPCS, Revenue codes, Diagnosis codes, state specific codes, etc.
Effective time management and organizational skills
Ability to perform independently and handle multiple projects simultaneously and able to meet frequently changing work demands
Ability to establish and maintain positive and effective working relationships with all levels of personnel and external customers
Ability to effectively communicate with multiple levels of personnel both verbal and written
Ability to make decisions, take action, follow tasks to completion
Ability to establish staffing needs to support business needs
Maintain confidentiality and comply with HIPAA and compliance policies
Job Type: Full-time
Job Location:
Anaheim, CA
Required education:
High school or equivalent
Required experience:
computer skills to include working knowledge of MS Office programs: 3 years
Medi-Cal claims processing in health plan, MSO, or IPA/medical group settings: 5 years
Claims Management in health plan, MSO, or IPA/medical group settings: 3 years
Medicare claims processing in health plan, MSO, or IPA/medical group settings: 5 years
developing Policies and Procedures and effective training materials and action plans: 3 years
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