Job Description

As the Manager, Claim Operations you will play a key role in Guidehealth’s expansion and growth. You will provide operational oversight to the claims production and the inventory and reporting teams to ensure all required KPIs and Metrics are being met. This role will report to the Sr. Director, Claims Operations.

WHAT YOU'LL BE DOING

• Responsible for the day-to-day management of the Claim Operations team.
• Maintains and improves claims processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans.
• Assessing and assigning workflow, coaching, counseling.
• Use reporting data analytics to track KPIs and report to leadership on a daily, weekly, monthly basis.
• Monitor individual Analysts quality and production measures, conducting staff performance conversations, monthly 1:1’s with individual staff to review their concerns, give feedback, mentor goals and career progression.
• Responsible for writing and maintaining desktop procedures for claims processing functions.
• Identify areas within the claims workflow and system tools where the processes can be improved/enhanced, analyzing current workflows, designing and implementing changes to streamline operations and monitor the impact of those changes to ensure increased efficiency and production.
• Leveraging technological advantages and incorporating new workflows to scale the business.
• Responsible for the distribution and completion of assigned JIRA tickets relating to claims inquiries or adjustments requests.
• Complete first round of claims processing reviews on client reporting requirements prior to sending for their approval.
• Coordinate operational workflows and other internal functions alongside departments and managers.
• Participate in the Monthly Policy and Procedure committee meetings, complete review of policies to approve or suggestions for updates.
• Conduct at minimum monthly team meetings, and attend operational meetings as requested.

Qualifications

WHAT YOU'LL NEED TO HAVE

• Minimum 3 - 5 years’ experience in Management of a claim operations.
• Demonstrated skill in managing change and in team building
• Advanced knowledge of claims processing including deep knowledge of claims data analysis, and the setting, tracking and reporting on performance metrics.
• Proficient with Microsoft applications, Excel, Word, Access and Power Point.
• Experience with HMO Medical insurance claims with in-depth understanding of federal and state regulations.
• Demonstrated skill in problem solving, exercising initiative, and decision-making within scope of role.
• Thorough understanding of claims processing compliance requirements.
• Ability to meet deadlines and prioritize tasks and assign work daily to the staff. Demonstrated project management experience.
• Ability to work independently with minimal supervision. Exceptional judgement in escalating concerns to next level leadership.
• Exceptional written, visual and verbal communication is necessary to lead a team and convey clear instruction.
• Change management skills are necessary in order to engage a team as we grow.
• Continuous improvement and a growth mindset are required.
• Claim coding experience, coding edits experience.
• CPT and ICD coding knowledge and medical terminology

What we’d love for you to have

• Bachelor’s degree in healthcare administration, business, or related field
• Strong understanding of healthcare regulations, insurance contracts, and reimbursement processes.
• Analytical skills with an ability to interpret healthcare data and claims information.
• Certified Professional Biller (CPB), Certified Professional Coder (CPC), or other similar certifications.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
• Claim coding experience, coding edits experience.

Additional Information

The salary for this role is $80,000.00 per year.

BENEFITS:

While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer Flexible Time Off tailored to meet your needs and the needs of the business, helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT

Diversity, inclusion, and belonging are at the core of Guidehealth’s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.

OUR COMITTMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth’s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The recommended internet speed is a minimum of 50 mbps download, 10 mbps upload. Please consult with your internet provider or run a speed test here to confirm your internet connection meets these requirements.