Manager, Claims Data Operations

Job Summary

The Manager of Claims Data Operations leads and manages the Technical Project Analysts and the Business Analysts in the completion of day-to-day operations. The Manager directs the process improvement and re-engineering efforts to ensure EDI activities ranging from intake through payment of provider claims are effective, efficient, and streamlined. This position is responsible for the oversight, remediation, and enhancements of the Member Out of Pocket Accumulator business process for all applicable lines of business.  In addition, the Manager is responsible for the Electronic Load of Delegated Authorizations (ELDA) as well as the loading of all internally created authorizations into QNXT. This includes the end to end process improvement re-engineering initiative to ensure cross-functional process improvement teams are formed in order to identify potential business inefficiencies and corresponding I.T. redesign opportunities; develop solutions, and implement timely process improvements to maximize the quantity and quality of authorization data resulting in an increase and accurate claims payment and auto adjudication of claims. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. 

Duties

Plan, organize, direct, staff, and develop activities of assigned functional areas(s). Contribute expertise and specialized knowledge to work activities. Manage, coach and mentor analysts for improved functioning as needed. Monitor teams' output and ensure the work produced by the team is consistently of high quality. Ensure business activities are effective, efficient, and streamlined in order to contribute towards the accuracy and timeliness of claims payments.

Ownership of the End-to-End Accumulator process. Oversight of the transmittal of files, claims, encounters, etc., with accumulator information.  Validation of the Maximum Out of Pocket (MOOP) data throughout the system (intake/accumulator DB/QNXT/threshold certificates) to ensure accuracy of member out of pocket calculations. Direct the timely remediation, as appropriate, for member reimbursement and issue tracking/resolution.

Oversight of authorization data as it flows through-out L.A. Care's various systems. Manage the development of reports to track end to end reporting of authorizations from ELDA to QNXT; focus on timeliness, errors and timeliness to correct, volumes (understanding volumes being loaded into the system).

Manage cross-functional work, as needed, to improve authorization timeliness and success rates for loading into the system as well as increasing the number of authorizations (ELDA & CCA/SyntraNet) that successfully get loaded into QNXT. Oversight of development, implementation, and ongoing monitoring and enhancement of roadmap to eliminate the need for examiners to search for authorizations manually.

Collaborate with cross functional teams to analyze and validate data, identify root cause issues and propose solutions which incorporate technology and people solutions. Address business inefficiencies; systems and otherwise.    

Develop goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 6-8 years of experience working with healthcare data.

Minimum of 3-5 years of supervisory/management experience in a healthcare setting

Prior experience working with healthcare data from a managed care environment.

Working knowledge of health plan eligibility and enrollment processes.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Preferred:

Experience with writing business and functional design documents.

Experience developing test cases and leading UAT sessions.

Working knowledge authorization data.

Commercial health plan experience.

Skills

Required:

Must have solid understanding of project management methodologies and be able to assess appropriate methodologies for the work assigned to the unit.

Ability to interpret and apply complex operating instructions, state and federal regulations, and department/division procedures. Ability to understand, apply, and communicate rules, regulations and guidelines to others.

Strong analytical skills, attention to detail, strong oral and written communication skills, and the ability to self-start and self-motivate.

Proficient in SQL, MS Access, MS Excel, MS Word and Outlook.

Ability to perform extensive root cause analysis of problem areas and recommend alternative solutions.

Strong coaching/mentoring skills, team building skills and the ability to work effectively with diverse team members.

Must be able to work in an environment where critical time constraints exist.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information