Experience & Specifications:

1.      Bachelor’s degree in business administration or related discipline is necessary; master’s degree preferred

2.      Experience: 5+ years in a supervisory or management relating to claims management and oversight

3.      Must have a thorough understanding of insurance-related legal procedures, regulations, and claims processing

4.      Strong proficiency in Microsoft Office computer programs including Excel, Word, and other programs is necessary

5.      Knowledge and Skills:

·        Excellent organizational skills

·        Medical terminology, coding nonmenclature such as CPT, HCPCS, CDT, ICD10

·        Medicare rules and regulations and US health insurance industry standards

Job Summary:

Reports directly to the Sr. Health Plan Finance Manager and responsible for providing leadership and management oversight to the Claims team in Guam and Philippines assuring the attainment of service and operational excellence; process efficiency, processing and payment accuracy and other pertinent claims related functions. 

Essential Duties and Responsibilities:

1.      General Management 

1.1.   Ensures accuracy, timeliness and completeness of claims data entry for all medical, prescription, dental and hospital facility claims in the claims systems.

1.2. Ensures the timely, accurate and complete processing and auditing of all medical, dental and facility claims on the claims systems based on established performance goals and objectives.

1.3.   Manages and oversees the performance of the claims team and ensure adherence and achievement of the claims team daily, weekly and monthly performance and operational goals and objective.

1.4.   Manage and handles all legal and litigation related issues to ensure company’s interests are properly protected and minimize potential liability.

1.5.  Responsible for training and orientation of new and tenured employees with TakeCare claims processing guidelines, objectives, goals, expectations, and any changes in claims, conding and billing standards.

1.6. Ensures compliance with claims related performance guarantees under TakeCare’s federal/OPM, Government of Guam, Judiciary of Guam and other private/commercial employer group performance guarantees.

1.7.   Manages and reports any claims team performance objectives and goals and provides it to both the Quality Improvement and Risk Management committee.

1.8.   Performs monthly audit of processed claims to ensure accuracy goals and objectives are met.

1.9.   Manages the fraud, waste and abuse program relating to proper coding and billing guidelines and ensures the avoidance of any improper payments of claims.

1.10. Ensures the appropriate, accurate and timely processing of claims with other insurer following the coordination of benefit process and guidelines and the timely  recovery of any overpayments to the appropriate member and/or provider.

2.      Department Engagement 

2.1.   Works closely with claim staff to create an efficient, timely, effective and accurate workflow in the department and implement measures to minimize unnecessary payments. Establish daily, weekly and monthly operational and performance goals and objectives for each processor and the entire claims team.

2.2.   Works closely with Underwriting team to ensure that risk management and loss control strategies are utilized and implemented to ensure claims were processed based on the eligible member’s benefit plan and minimize any inappropriate payment of claims.

2.3.   Works closely with Contracting department to ensure that claims are processed based on agreed provider fee schedules/structures and minimize inappropriate payment of invalid services based on the provider’s agreement/contract.

2.4.   Works closely with the Medical Management team to ensure claims are processed based on approved referrals and prior authorized services.

2.5.   Works closely with the Health Plan Finance team to ensure timely and accurate reporting of reinsurance claims.

2.6.   Works closely with the Business Configuration team to ensure provider fee schedules/structures and benefit plans were set up accurately and timely and these are able to be administered in the claims systems. 

3.      Maintenance Administration 

3.1.   Takes an active role in all current and future large claims ($5K up to $50K) review and approval.

3.2.   Participates actively in the Fraud, Waste and Abuse process to ensure that loss controls are implemented to avoid the processing of inappropriate claims.

3.3.   Ensures timelines for claims, prompt payments and special projects are met.

3.4.   Performs monthly reviews of overrides performed by the claims staff to ensure that overrides are properly done and performed by each processor.

3.5.   Ensures achievement of all operational and departmental goals such as but not limited to timeliness and accuracy of processing.  

4.      Behavioral Competencies

4.1.   Articulates issues or problems from a broader organizational/mission perspective.  Builds the case for change and articulates costs and risks for not making change.

4.2.   Willingness to take calculated risks.  Recognizes situations of “sunk costs” and the necessity to shift focus.

4.3.   Leads inspirationally, nurtures commitment to company’s vision and shared values.

4.4.   Anticipates and pushes change through the organization, equipping staff to adapt quickly.

4.5.   Facilitates holistic thinking/problem solving and integrates efforts/results.

4.6.   Tactfully mitigate conflict and performance development issues in a demeanor that promotes behavioral change.

4.7.   The ability to handle a demanding workload, yet meet positional and company objectives under pressure.

4.8.   Results and accountability driven, with a track record to prove it.

4.9.   Accurate judgment of issues to expend energy to.  Able to quickly shift focus.

4.10.   Ability to fully engage employees, capture their loyalty and extend their capabilities.

4.11.   Diplomatic in managing internal dynamics and operations.  Effectively manage the engagement and collaboration of groups and functions to achieve a common goal.

4.12.   Accepts accountability for actions and decisions.  Wiliness to self-correct, change and grow.       

4.13.   Demonstrates strong negotiation, influencing and analytical skills