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Employment Type:
Full time
Job Category:
Health Care Provider
Health Care & Medicine
Manager, Claims Operations
(This job is no longer available)
UCLA Health | Los Angeles, CA
Grad Date

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Job Description

Job Duties
The Manager, Claims Operations is responsible for the planning, development and implementation of administrative and operational Claims functions in adjudicating FFS and Capitated claims for authorized services, timely, accurately and consistent with member benefits and in compliance with contractual, State and Federal regulations. The incumbent will implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments. The Manager will establish methods for continuous monitoring/auditing of workflows to ensure the integrity and goals of the processes remain consistent and to identify potential opportunities for improvement. The Claims Operations Manager is accountable for the oversight and coordination of the following major functions: Claims Operations Program, Coordination of Benefits, Appeals and Overpayment Recoveries, Audit/Quality Control, Claims Edit Business Rules/Configuration, Retrospective Review, Customer Service, Claims Mailroom

Job Qualifications
High school diploma Bachelor's degree in healthcare administration, business administration, or a related field preferred. Minimum of five (5) years previous experience in claims operations specifically related to managed care in a complex and diversified healthcare or health insurance company. Minimum of three (3) years' experience managing personnel with at least two (2) years managing personnel in a claims processing environment. Strong working knowledge of provider network/IPA arrangements and reimbursement methodologies and of health benefit plan concepts such as limitations, exclusions, carve-outs, coordination of benefits, benefit accumulators, member and plan responsibilities,, authorization requirements, recoveries, and the appeals process. Must have extensive knowledge of physician and facility billing practices, appropriate CPT coding initiatives, ICD-9/ICD-10 coding standards related to specificity, as well as Revenue and HCPCS coding. Conversant with standard electronic and paper claim formats; familiarity with American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) coding guidelines such as the National Correct Coding Initiative (NCCI) edits and their relation to clinical logic in claims adjudication Must be familiar with all regulatory standards such as HIPAA, DMHC, AB1455, and CMS reporting requirements.? Demonstrated computer skills; proficient with Microsoft Windows applications including but not limited to Excel, Word and Outlook as well as ability to conduct Internet based research Familiarity with Microsoft Access and/or SQL a plus. Extensive knowledge of one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXT. Familiarity with claims edit software i.e. Optum CES, McKesson etc. Sound and independent judgement and the ability to think and conceptualize beyond existing barriers, methods and practices.? Strong leadership skills, with the ability to articulate goals, plan and implement processes to achieve those goals, recognize and assess the implications of confounding variables, anticipate consequences, and meet deadlines. Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardizations exist. Effective oral, written communication and presentation skills sufficient to communicate clearly and grammatically both complex and simple messages to a wide audience either within or outside of the organization Detail-oriented without losing sight of broader perspectives. Ability to travel/attend off-site meetings and conferences.

About UCLA Health

For more than half a century, UCLA Health  has provided the best in healthcare and the latest in medical technology to thepeople of Los Angeles and throughout the world. Today we are one of the most comprehensive and advanced healthcare systems in existence. We are comprised of Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, Resnick Neuropsychiatric Hospital at UCLA, Mattel Children’s Hospital UCLA, and the UCLA Medical Group, with offices throughout the region.

Ronald Reagan UCLA Medical Center is consistently ranked by U.S.News & World Report as one of the top five hospitals in the nation and the best medical center in the western United States. The doctors, scientists and caregivers of UCLA are leaders in their fields. Every day, they perform pioneering work across an astounding range of disciplines, from organ transplantation and cardiac surgery to neurosurgery and cancer treatment. Year after year, our people have achieved medical breakthroughs and earned the highest industry honors. And we’re just getting started.

The dedicated professionals of UCLA Health are committed to healing humankind, one patient at a time, by improving health, alleviating suffering, and delivering acts of kindness on a daily basis.