Manager Claims Healthcare

About the role

This position will be responsible for developing strategies to optimize the claims audit/review process, overseeing the completion of claims audits/reviews of delegated vendors to ensure compliance with health plan and regulatory standards and internal policies, monitoring key performance indicators (KPIs) to ensure accurate and timely claims processing, and ensuring that third parties adhere to agreed-upon delegated authority contracts and performance standards. The role leads a team of claims analysts and works closely with the Network Management, Utilization Management, Business Intelligence, Member Services, Compliance, and Finance departments.

About us

VillageCare is a community-based, not-for-profit organization serving people with chronic care needs, as well as seniors and individuals in need of continuing care and managed care services. Our mission is to promote healing, better health, and well-being to the fullest extent possible. Our care is offered through a comprehensive array of community and residential programs, as well as managed care. VillageCare has delivered quality health care services to individuals residing within New York City for over 45 years.

Responsibilities

• Develop strategies to optimize the claims audit/review process.
• Oversee the completion of claims audits/reviews of delegated vendors to ensure compliance with health plan and regulatory standards and internal policies.
• Monitor key performance indicators (KPIs) to ensure accurate and timely claims processing.
• Ensure third parties adhere to agreed-upon delegated authority contracts and performance standards.
• Lead a team of claims analysts.
• Collaborate with Network Management, Utilization Management, Business Intelligence, Member Services, Compliance, and Finance departments.

Requirements

• Minimum of 5+ years' experience in claims analytics performing increasingly complex data analysis and report/dashboard development in a healthcare setting.
• At least 2 years' experience managing and training staff.
• Knowledge of medical terminology, ICD-10, CPT, HCPCS coding, CMS guidelines, and Encoder Pro.
• Ability to work independently with a high level of productivity.
• Advanced written and verbal communication skills.
• Excellent technical skills (MS Excel, SQL, Tableau, etc.).
• Must reside in NY, NJ, or CT (hybrid work arrangement).

Qualifications

• Bachelor's Degree.

Pay

$118,135.58 - $132,902.53