Claims System Process Improvement Program Manager, Bakersfield, CA

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Claims System Process Improvement Program Manager

Kern Family Health Care, 2900 Buck Owens Blvd., Bakersfield, California, United States of America Req #2128

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the Claims Systems Process Improvement Program Manager position in the range of $85,451- 110,808/ Annual

Our Mission. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

Definition

Under management direction, responsible for supervising the testing, configuration and auto adjudication activities in the Claims Department to ensure accuracy of claims payments and improved auto adjudication. This position will have two direct reports.

Distinguishing Characteristics

This position is responsible for supervising the claims testing and auto adjudication improvement efforts for a Knox-Keene licensed health maintenance organization (HMO).

Essential Functions

• Leads, trains, develops and evaluates assigned staff. Applies personnel policies and ensures the continual development of staff
• Perform audit of claims core processing system to help improve auto adjudication and accurate provider payments
• *Perform audit on claims editing software system to help improve auto adjudication and accurate provider payments
• Assist in defining test case scenarios for application and configuration testing
• Participate in system enhancements, modification and upgrades
• Performs initial investigation and evaluation of system design findings by building proof of concepts in the Test module
• Oversee testing team for new contracts, updates and any system changes related to claim
• Continually reviewing Dispute data and audit errors to find trends to improve auto adjudication and accurate provider payment.
• Manages team production, workloads and priorities.
• Ensures team compliance and adherence to established team performance standards.
• Ensures timely performance measurement and assists in the identification and implementation of improvement initiatives.
• Researches and resolves provider payment issues related to system configuration.
• Attend and participate in internal and external meetings regarding system configuration that are claims related business.
• Keep Director, Deputy Director and Manager informed of any issues or concerns.
• Report system issues to the appropriate staff person.
• Completes monthly individual performance plan reviews and yearly performance appraisals for staff.
• Provides monthly report to management.
• Perform all other related duties as assigned.

Other Functions

• Assist Director and Deputy Director of Claims and Manager of Claims in improving auto adjudication, payment accuracy and examiner accuracy.
• Performs other job-related duties as required.
• Adheres to all company policies and procedures relative to employment and job responsibilities.

Employment Standards

Bachelor’s degree in Healthcare or Business Administration or related field from an accredited institution; AND a minimum of four (4) years of experience in health care with emphasis in coding, financial rate set up or claims processing in a managed care environment;

-OR-

Six (6) years or more of experience in health care with emphasis in coding, financial rate set up or claims processing in a managed care environment;

One (1) year experience in system configuration required, preferably with QNXT required.

Two (2) years supervisory experience required.

Moderate understanding and experience in the use of the structured query language (SQL) in a large operational data store or warehouse required.

Health maintenance organization (HMO) claims payment-processing experience is highly desirable.

Knowledge of : Candidate needs strong analytical, prioritization and time management skills. Microsoft Office skills. Needs to be self-motivated and results oriented with an ability to work with multiple departments.

Must be knowledgeable of medical claims data, formats and restrictions including but not limited to Revenue Codes, Place of Service codes, ICD-10 codes, CPT Codes, and Modifiers. Experience in Medicaid environment is beneficial.

Ability to: Adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities; communicate with a variety of personnel and providers; prepare management reports; effectively supervise and train staff.

Other: Possession of valid driver’s license and proof of State required auto liability insurance. Required Travel Up to 10%

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

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