Medicare - Claims Processing Manger

Job Description:  The Medicare Claims Processing Manager is the lead person responsible for the total claims processing functions within a specified multi-state jurisdiction for a Medicare Administrative Contractor (MAC) operations.  Claims processing includes Front End functions (i.e. Electronic Data Interchange interface, paper claims intake, document control, provider direct data entry support, suspended claims development, preparation for Medicare standard systems adjudication) and Back End functions (i.e. print and mail of required paper documents for Medicare beneficiaries and providers, including check printing) for both Part A and Part B.  Must constantly analyze operational workflow to ensure quality, quantity, required timeframes, and efficiency standards are satisfactorily met.  Supervises staff and oversees any integral sub-contracts, plus Joint Operating Agreements with Medicare specialty contractors.  Prepares required reports for CMS and ACS.

 



 

Basic Requirements

The Claims Processing Manager shall possess eight years of health care claims processing experience, with a minimum of three years prior management experience within a Medicare claims processing operations (a CMS government requirement).

 

The Claims Processing Manager shall be fully dedicated to this A/B MAC contract and will not be responsible for other claims processing operations (Medicare or non-Medicare).

 

Preferred Work Experience:  Prior experience with both Medicare Part A (intermediary) and Part B (carrier) claims processing operations is highly desirable. Comprehensive knowledge of health care claims processing and related quality control procedures in the areas of electronic data interchange transactions, incoming paper claims, document control, provider direct data entry support, electronic billing software, third party liability,  claims tracking, suspended claims development, claims processing interfaces, and back end print & mail functions.Participation in a government-contract workload transition between claims processing contractors.

 

Other Requirements:Ability to successfully handle multiple complex tasks.Excellent management experience and communication skills.Commitment to continued improvement within the claims processing environment.Timely fulfillment of Medicare-specific reporting requirements for the following and other CMS reports:  Paper Claims Activity, Workload Report for Payment of Claims Outside CWF, DNF Initiative, Physician Private Contracting, HPSA, Physician Incentive Payment, Relocation to a designated work site location within the MAC jurisdiction after contract is awarded (likely to occur in the Fall of 2007).Willingness to travel for proposal-development purposes during 2006 and 2007.

  Minimal job-related travel following contract award.

 

Education:  Bachelor?s degree preferred.  Ten years relevant experience in health care claims processing may be substituted for a college degree.