Claims Manager(Health Insurance TPA)

Company: People Premier
Location: Clearwater
Posted on: May 12, 2022

Job Description:

Overview:Premier Administrative Solutions (PAS) is looking for an experienced Claims Manager with Health Insurance and TPA (third party administrator) experience.We are a growing and innovative benefits management company (TPA) providing a full suite of quality insurance products and services.Since 1994, PAS leadership has been working side-by-side with carriers, agents, and customer service representatives nationwide to create a dynamic, modern approach to the marketing and administration of a variety of innovative insurance products.Job Type: Full-TimeSalary: Starting at $85,000Benefits: Health Insurance Dental and Vision Insurance Paid Time Off Life Insurance Paid Holidays 401K Fun and exciting work environment!Responsibilities:As the Claims Manager, you will be responsible for the day-to-day management of theClaims Department, providing strong leadership and directives that will clearly articulatedepartment objectives and timeline expectations. You must be proactive in foreseeingdaily workflow issues and resolving these issues with staff and systems resulting inmeeting organization objectives, client performance guarantees and key operationaland quality metrics.The Claims Manager will be responsible for management functions; expertise in theclaims management and adjudication functionality of the CaMPS or alternative claimsadministration platforms; managing relationships with vendors used in the claimsadministration process; and in ensuring that PAS meets or exceeds the claims serviceexpectations of clients.Management Responsibilities Development and management of a staffing plan and budget for the ClaimsDepartment. This includes development and ongoing monitoring of standardsfor auto-adjudication and production requirements for Claims Departmentstaff. Monitoring of service performance metrics, including timeliness, accuracy,compliance and satisfaction. Interfacing with Management and Staff of clients to address concerningtrends in claims utilization and submissions, including higher-level serviceissues or plan interpretation.System and Control Expertise Responsibilities Positioning as a subject matter expert (SME) on the claims administrationfunctionality of CaMPS or succeeding platforms as it relates to the mostefficient delivery of claims administration services for clients. Identification of Policies and Procedures which should be documented in theClaims Department and working with the Enterprise Risk Management (ERM)Department and Training Coordinator to ensure that those Policies andProcedures are complete and appropriately updated. Participation in the implementation and ongoing management of vendorsselected to enhance PAS' claims service to clients and covered individuals. Implementation and oversight of a "system of controls" as called for in SSAE18/SOC 1/SOC 2 related to financial and operational controls.Administrative Task Responsibility Oversight of organizational structure designed to maintain high levels ofefficiency and accuracy in the processing of claims. Hiring Manager for all new team members, ensuring that experienced, quality-oriented staff are hired for open positions with enough lead time to ensurecontinuity of production. Development of a comprehensive set of appropriate and reportable metricsfor managing the Department, evaluating staff and reporting to clients. Analyze claims workflows and processes to identify inefficiencies and executea vision to streamline efficiencies. Detailed analysis of audit program results to identify trends and performancemanagement issues. Implementation of training and other initiatives toimprove quality. Management of appropriate security measures, including schedules ofrelease authority for staff and individual Claims Manager responsibility forhighest dollar claims release. Implementation of resources and procedures to review requests forreconsideration, appeals and complaints.Review/verification of weekly client funding requests to ensure consistencywith the Claims Manager's expectations based on most recent production.Qualifications:- Recent Claims experience in Healthcare industry is a must.- Previous management experience required.- At least 5-8 years of experience with TPA claims administration services,including designing workflow, managing via a series of metrics, implementingoperational controls and using quality assurance results to design and implementquality improvement programs.- Must be a college graduate; business or accounting background is desired.Environmental Factors/Physical Demands:Work is performed in an office and onsite facility care environment. While performingthe duties of this job, the employee is regularly required to have the ability to maintainactive customer and employee communication; access, input and retrieve informationfrom the computer system; enter alpha-numeric data into a computerized system oftenwhile listening on the telephone. May be subject to repetitive motion such as typing,data entry and vision to monitor. May be subject to bending, reaching, kneeling,stooping and lifting up to thirty (30) pounds.HP123

Keywords: People Premier, Clearwater , Claims Manager(Health Insurance TPA), Executive , Clearwater, Florida