Sign in

Third Party Medical Claims Manager MN #5012

Company:
Absolute Opportunities
Location:
Minneapolis, Minnesota, United States
Posted:
November 11, 2018

Description:

Third Party Medical Claims Manager – MN #5012

Relocation No

Location Minneapolis MN

TPA Medical Claims Manager

Company administers self-funded medical and defined contribution plans for employers and other entities through its wholly owned TPA subsidiary. The TPA Medical Claims Manager is responsible for the entire claims experience including; accuracy, quality and turnaround time, as well as the network and vendor contracts for the TPA.

YOU WILL:

● Collaborate across teams to create and deliver an amazing medical claims processing experience to our members, their employers, and internal stakeholders.

● Establish processes and procedures to support the medical claims processing flow that supports the full range of claim types, including office, pharmacy, and hospital.

● Identify TPA process intersections with other areas of the business, and train and communicate processes as necessary.

● Oversee claims processing workflow. Identify improvements to the claims processing and adjudication process, including implementing and maintaining auto adjudication, and ensuring high quality and low turnaround time.

● Establish adjudication processes and audit parameters to ensure claims are approved or denied for payment by ensuring the payment is correct, verifying the proper authorizations were submitted, and resolving any system hold codes.

● Ensure the TPA is capturing COB savings by coordinating payments of claims between insurance companies when more than one insurance company is involved.

● Oversee a stop-loss claim process to ensure that high dollar claims are reviewed and processed accurately.

● Manage and oversee all vendor relationships. Partner with the Process Improvement Manager to prioritize and execute the VBA roadmap.

● Analyze data and report on key metrics related to claims processing, enrollment, payment to providers, vendor utilization and stop loss.

● Propose solutions to support effective practices and communicate potential areas of risk.

● Perform occasional day-to-day TPA activities as needed and act as the go-to person for escalated and complex issues that arise.

● Partner with the Process Improvement Manager to Improve and grow our TPA function as needed and support new business initiatives.

● Work closely with Compliance to ensure all practices meet or exceed regulatory requirement.

● Work closely with Analytics and other departments to provide necessary reporting to support the TPA solutions.

YOUR BRING:

Our ideal candidate is a highly motivated, goal-oriented, team-focused leader who has enough experience with third party administration to establish a new function and lead it successfully.

● Experience with all facets of health payor TPA’s operations

● 5+ years medical claims adjudication and processing experience

● Knowledge of medical coding terminology, CPT, Revenue codes, ICD 9/ICD 10, as well as claims processing rules, managed care benefits and auto adjudication

● Working knowledge of ACA (Affordable Care Act) compliance and subject matter expertise required

● Strong technical aptitude and previous experience working with an IT department to establish and smoothly operate a claims system.

● Previous success establishing workflow and processes.

● Flexible attitude and ability to develop creative solutions in a fast-paced startup environment

● Strong communication skills

● Excellent organizational skills

Bottom line requirements we need notes on with candidate submittal:

1. Experience with all facets of health payor TPA’s operations.

2. 5+ years medical claims adjudication and processing experience.

3. Knowledge of medical coding terminology, CPT, Revenue codes, ICD 9/ICD 10, as well as claims processing rules, managed care benefits and auto adjudication.

4. Working knowledge of ACA (Affordable Care Act) compliance and subject matter expertise required

5. Strong technical aptitude and previous experience working with an IT department to establish and smoothly operate a claims system.