Manager, Claims Operations

About the role

The Manager, Claims Operations reports to the Director, Claims and is responsible for the performance of the San Francisco Health Plan (SFHP) Claims Department. Key responsibilities include ensuring compliance with regulatory and contractual requirements, managing staff performance, training, and skill development, providing metrics, overseeing workforce allocation and analysis, and participating in audits.

Responsibilities

• Lead and manage claim operations, including first pass claims processing, recoveries, provider disputes (PDR), payment integrity and overall performance of the SFHP Claims Department.
• Build and develop teams into cohesive units.
• Ensure compliance following all regulatory and contractual requirements.
• Motivate Claims staff and take necessary steps to ensure service is always provided to both internal and external customers.
• To ensure accurate claims payment, documentation and remittances.
• Monitor aging and accuracy of paid claims to ensure departmental metrics are met.
• Identify, implement and monitor appropriate performance metrics aligned with SFHP organizational goals and objectives.
• Prepare, analyze and act upon claims statistics, reimbursement trends and team performance metrics.
• Ensure that all claims are processed accurately and efficiently following SFHP policies, processes and procedures.
• Ensure timely, accurate and thorough responses are given to all provider dispute requests (PDR) and inquiries regarding claims status and other claims information in compliance with regulatory requirements.
• Identify trends and resolutions to reduce PDR.
• Ensure communication with all internal and external stakeholders.
• Meet with other departments that impact Claims to resolve problems.
• Demonstrate ability to determine root cause of issues to create appropriate solutions.
• Work with appropriate technical staff to design, develop, enhance, modify and utilize claims data reporting tools.
• Provide SFHP management with trend analysis and other analyses.
• Work with appropriate technical staff to design, configure and test modifications to claims adjudication software and ancillary systems.
• Work with main staff to research, report and resolve any routine problems with claims payment processes.
• Monitor and evaluate staff performance, attendance and punctuality. Provide ongoing, constructive and objective performance feedback. Take corrective action promptly when inappropriate behavior and/or performance related problems arise to foster improved performance and early problem resolution.
• Oversee and develop staff to achieve mastery in their current roles and cultivate them for more advanced roles in the organization.
• Hire and train new team members properly. Take steps to distinguish and ensure acknowledgment and retention of high performers.
• Direct and manage internal or interdepartmental projects.
• Manage department budget.
• Lead department participation in all regulatory and financial audits, including resolutions of audit findings.
• Create new policies and procedures.
• Define internal department audit requirements based on results on monthly random audit, Contract and Compliance audits and external audits.
• Oversee claims user acceptance testing for projects and system changes to ensure they are completed thoroughly.

Requirements

• Bachelor's degree in a related area or equivalent work experience required.
• Four years of prior relevant management experience.
• Five years working experience in a health care environment, preferably in managed care, Medi-Cal, Medicare or other government program.
• Experience handling PDRs.
• Demonstrated experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication.
• Expertise in standard claims processing systems and claims data analysis.
• Working knowledge of claims coding and medical terminology.

Qualifications

• Bachelor's degree in a related area or equivalent work experience required.
• Four years of prior relevant management experience.
• Five years working experience in a health care environment, preferably in managed care, Medi-Cal, Medicare or other government program.
• Experience handling PDRs.
• Demonstrated experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication.
• Expertise in standard claims processing systems and claims data analysis.
• Working knowledge of claims coding and medical terminology.

Skills

• Strong leadership and management skills.
• Excellent interpersonal and communication skills.
• Proven ability to handle complex issues and provide effective solutions.
• Knowledge of healthcare regulations and standards.
• Proficiency in claims processing systems and procedures.
• Ability to analyze data and make informed decisions.
• Strong analytical and problem-solving skills.
• Effective time management and organizational skills.

Benefits

Health Benefits: Medical, Dental, Vision, Retirement (employer-matched CalPERS Pension and 401(a) plans, 457 Plan), Paid Time Off (PTO), and 13 paid holidays.

Pay

$140,000 - $150,000 per year

Schedule

This is a hybrid position, based in our Downtown San Francisco office. You are required to be onsite and in-office a minimum of 4 days per month.