Manages the activities of claims administration, contracted provider reporting and processing of invoices for non-claim services. Serves as a liaison between the Third Party Administrator (TPA), contracted providers, and CCC staff to manage provider reimbursement process, including acting as the first point-of-contact with providers to identify and resolve reimbursement issues.
Has a wide variety of responsibilities related to managing relationships with our healthcare service providers as well as handling management of our Third Party Administrator (TPA).
Duties and responsibilities include:
• Delivers excellent customer service and helps build positive relationships with the CCC provider network by effectively resolving issues and coordinating a smooth reimbursement process;
• Develops and maintains policies and procedures relevant for all job duties and responsibilities, and cross-trains other staff to ensure continuity with same;
• Manages the claims processing for health care services, including oversight of the CCC's Third Party Administrator (TPA) contract and the CCC's internal, manual claim/invoice processing systems;
• Reviews “Request for Funding” files from the TPA for identification of claims adjudication issues and for accuracy of new contract implementations and TPA configurations;
• Coordinates the configuration process of providers and benefits with the TPA
• Resolves financial and operational reimbursement issues associated with each contract;
• Ensures the accuracy of the CCC online MAP Provider Manual. Directs and monitors staff conducting new provider orientations and in-service training; and
• Manages the encounter data and other file exchange from various sources within the CCC.
• Works with analytics staff to define reports/dashboards and review with CCC staff.
Performs other duties as directed by the CCC Leadership, and as otherwise required.
KNOWLEDGE, SKILLS, AND ABILITIES
• Knowledge of the principles and practices of claims processing and payments;
• Knowledge of the principles and practices of managed care contracting, provider reimbursement and claims; payment, medical terminology and health care delivery systems;
• Knowledge of principles and practices of public sector procurement and contract administration;
• Ability to provide guidance and direction to subordinates, including setting performance standards and monitoring subordinates;
• Knowledge of general contracting principals, financial & operational procedures and practices; and
• Strong communication skills, including a proficiency in drafting business memos, contractual language, email, and in-person with facilitated meetings.
• While performing the duties of this job, the employee constantly is required to: grasp, handle, feel, see, and sit;
• The employee frequently is required to: reach, walk, talk, and listen; and
• The employee occasionally is required to: lift up to 25 pounds.
• Bachelor's degree in a related field of study or equivalent additional years of experience
• Minimum of five years of combined claims review and/or vendor/contract reimbursement management experience in a managed care environment
• Additional experience in a healthcare setting from the point of view of care delivery is a plus
• Knowledge of medical claim coding is a plus
• Demonstrated experience supervising staff preferred