Healthfirst

The Manager Claims Support Group is responsible for overseeing the daily operation of Sr. Provider Associates and Senior Examiners within the Claims Support Group who provide dedicated claims billing and processing support to Network Management and Providers (i.e. Facilities, FQHC, IPA, Ancillary, Behavioral Health and MLTC Providers.

Duties and Responsibilities: Play a key role as Subject Matter Expert (SME) to support internal Operations staff and vendor resources as required. Support the development and operationalizing of departmental initiatives and strategies by working with Operations’ leaders and Project Management to help define business requirements and other process documentation for such initiatives, including standards for measuring effectiveness post-implementation. Perform departmental analyses for process appraisal and improvement; trend and compare against departmental and corporate standards and improve upon these processes using a Project Management approach. Develop additional analyses, where indicated, to enhance department’s ability to effectively determine root-cause (e.g. identify upstream errors), understand and act upon areas of deficiency. Recommend changes to address deficiencies and/or further improve and streamline performance based on analytical findings. Assess and prepare to address the operational impacts, workflow, and training issues of assigned projects. Identify the training and development needs of the internal Operations staff and vendor resources. Play a key role in the implementation and management of the Problem-Tracking & Feedback Loop process. Provide resource planning and resolution of issues to support the test (UAT) efforts of new initiatives. Assist with assuring that the appropriate level of quality is being consistently met, internally and externally, by working with the Quality Assurance department to understand quality measures and protocols. Coordinate and lead ongoing meetings with internal and vendor staff to assure process and programs are operating effectively. Work cross-functionally to recommend modifications to existing system set ups and review technical specifications to ensure business requirements are adequately reflected in technical planning documents. Assist with developing effective reporting tools for the department Prepare routine reports as needed (financial, quality, production, operational efficiency, etc.) Prepare presentations and deliver oversight reports of data analysis, vendor performance including the development of correction action plans when infractions are identified, and other project assignments. Additional duties as assigned or required Minimum Qualifications: Associates Degree from an accredited institution or equivalent work experience. Experience leading projects through a Project Management process. Experience leading project teams and independent projects within specific timelines. Demonstrated experience using SAS and Microsoft Office Excel to create, edit, and manipulate data. Experience creating and editing documents using Microsoft Word. Demonstration of related work experience in one or more of the following areas: Healthcare Services Operations, including transaction management Identifying defects and improving departmental performance by supporting quality, operation efficiency and production goals Analyzing various types of data and processes in a versatile manner and present findings and recommendations in a professional manner Preferred Qualifications: Bachelor’s Degree from an accredited institution. Significant experience in a healthcare services Operations capacity. Working knowledge of terminology applicable to healthcare settings. Experience with MHS and/or MACESS systems. Experience creating and editing queries in Microsoft Access. Knowledge of Medicare and Medicaid programs and reimbursement methodologies. Knowledge of healthcare claims processing practices in a managed care setting. Knowledge of healthcare services Medical Management programs and processes. Experience creating and editing workflow documents using Microsoft Visio. Demonstrated experience creating and managing projects using Microsoft Project. Compliance & Regulatory Responsibilities: N/A License/Certification: N/A

Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $98,400 - $142,205 All Other Locations (within approved locations): $84,400 - $125,545 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.