Job Description

Responsibilities

• Measure individual, system and performance of the Medical Claims Departments; ensure operating standards are met and implement operational objective of the department
• Review and correspond with vendors and Aetna partners on any claims related issues, to ensure all re-pricing are processed accurately and assist with re-pricing drug allowance on Medispan
• Test new changes in the Medical Claims Processing System (QNXT); establish system functionality, configuration and evaluate workflow requirements
• Resolve medical claims suspensions and responds to appeals; assist Supervisors and Staff with complex claims
• Assess supervisors and their staff performance To provide feedback when necessary
• Prepare departmental policies and procedures to ensure medical claims are processed accurately and in a timely manner; recommend system and policy changes
• Implement department wide initiatives and design training programs; ensure staff has the knowledge to perform essential duties, comply with relevant regulations and acquire the skills to achieve goals and objectives
• Supervise staff in accordance with established departmental and Human Resources guidelines and provisions of the Collective Bargaining Agreement
• Develop, prepare, and analyze various reports regarding operations and productivity
• Perform additional duties and projects as assigned by management

Qualifications

• Bachelor’s Degree in Health Administration or Business Management required
• Minimum of six (6) years relevant Medical Claims experience in a health benefits environment; to include two (3) years supervisory experience required
• Advance level in Microsoft Word and Excel preferred
• Extensive knowledge of medical claims processing, with extensive processing experience within a Taft-Hartley Fund CPT, ICD 10 and HCPCS
• Excellent leadership skills and ability to direct and motivate staff to meet and exceed standards
• Strong critical thinking, analytical and problem solving skills
• Superb communication and interpersonal skills