Demant

Manager, Claim Operations

Department AudioNet America
Job Locations US-MI-Clinton Twp
Job ID
2022-16865

Overview

ABOUT US

 
Birdsong Hearing Benefits™ LLC, is a hearing benefits manager that views hearing care as total care. We provide Medicare Advantage, including all lines of business in government programs, along with commercial solutions for the most under-utilized supplemental benefit: Hearing.
 
We are looking for dedicated, talented, and passionate individuals who want to join us in helping people awaken to the full sound of life. We are driven by the following values:
 
- People focused, realizing it is all about our consumers and each other.
- Collaborative with a strong team spirit, happy to work together to achieve greater results.
- Intuitive and creative, generating ideas and solutions to transform the hearing care ecosystem.
- Full of grit, wanting to work hard to achieve success.
- A growth mentality, eager to adapt and be flexible in an ever-changing environment

Summary

The Claims Manager is responsible for ensuring prompt and accurate claims processing. The Claims Manager is responsible for managing day to day execution of new day, adjusted claims processing, and facilitating member/provider inquiry, complaints, grievances, and appeals. The Claims Manager will have direct oversite and responsibility of claims processing on multiple systems for all lines of business to include subcontractors. To be successful in this role the claims manager must understand all aspects of claims processing from The Claims Manager is expected to be the subject matter expert (SME) on all claim life cycle processes.

 

 

Responsibilities

ESSENTIAL JOB FUNCTIONS

 

  • Working cross functionally with operations to resolve claim issues impacting encounter performance to ensure contractual requirements are met. Facilitate performance review meeting with segment claims and encounter teams
  • Responsible for recruiting, coaching, training, performance management of in office, hybrid, and full time remote staff
  • Responsible for claim operations processing to ensure KPIs are meet
  • Act as subject matter expert for claim submission requirements to ensure encounter acceptance including provider education and training sessions
  • Develops, monitors, and reviews performance reports and service performance trends for each account against the plan and recommends specific actions or remedies as necessary
  • Develops and maintains strong collaborative relationships within operations as well as with network management in establishing appropriate service level agreements
  • Creates and maintains tools, job aids, and training materials to help employees in their efforts to resolve issues and improve their relationship with customers
  • Collects, analyzes and reports on operations information in support of process, systems, and policy redesign
  • Effectively manages cross-functional projects that support the business strategy

 

 

Qualifications

PROFESSIONAL EXPERIENCE/QuALIFICATIONS

  • 5+ years’ experience in managing high volume transaction processing, financial management, project delivery, production, systems analysis and application program development
  • Demonstrated negotiation skills and problem-solving skills
  • Understanding of EDI ANSI X12 transactions
  • Multiple years proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes
  • Claim encounters experience is required
  • Experienced working with vendors
  • Customer service experience
  • Demonstrated proficiency with personal computer, keyboard navigation skills and with MS Office Suite applications (Outlook, Word, Excel, PowerPoint, SharePoint, etc.)
  • Ability to travel as needed
  • Must have reliable transportation, valid/active driver's license, and proof of vehicle insurance
  • Health Rules Payer claims system experience a plus
  • Vendor Management and oversite experience
  • Capacity to rapidly learn new software and processes

EDUCATION

High School Diploma/GED (or higher); Bachelor’s degree preferred

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