Office Locations: Durham, Wilmington and Charlotte, NC / Homebased position

 

The Claims Manager is responsible for understanding the processing, analysis and resolution of health insurance claims submitted by healthcare providers. This role is ideal for an individual with strong analytical skills, attention to detail, and leadership capabilities looking to understand and educate on the internal claims management process while contributing to operational improvements in the healthcare sector. The individual will work closely with internal teams, healthcare providers, associations and other stakeholders to support accurate claims adjudication while helping to support compliance with all regulatory and contractual guidelines.

 

•     Conduct detailed analysis of identified claims to ensure accuracy and compliance with healthcare policy, state regulations, provider contracts and billing practices

•     Primary point of contact for the Provider Experience (PX) Team to assist in resolving complex claims issues and escalations from providers, stakeholders and internal departments

•     Utilize claims data to identify trends or patterns in response to Provider feedback

•     Investigate discrepancies or questionable claims and work with the provider and internal teams to resolution

•     Maintain effective communication with the PX team, providers, and stakeholders by providing updates and issue resolution

•     Collaborate with the Claims Team to monitor claims projects and communicate across the team to resolution.

•     Provide claims training and development to the PX team members

•     Responsible for ensuring the PX team is prepared for JOC, claims and ad hoc meetings requested by providers related to claims concerns.

•     Attend JOC and Claims meetings as needed to provide high level claims insight and support

•     Prepare report out on findings tied to provider issues and concerns

•     Stay updated on changes in healthcare regulations, Centene, CCH, CCHN and State of NC medical policy for both Medicaid and Marketplace insurance.

 

•     Proficiency with claims management software and MS Office Suite

•     Strong understanding of health insurance policies, coding systems (ICD-10, CPT, HCPCS) and billing processes.

•     Knowledge of healthcare regulations, including HIPAA, Affordable Care Act (ACA), and Medicaid

•     3+ years of provider relations, health care operations, or medical management, and/or 5+ years experience in health insurance claims processing or a related field

•     Experience in Managed Healthcare or Medicaid/Medicare industry preferred.

•     Excellent written, oral, and presentation skills required.

•     Excellent analytical, organizational and problem solving skills

•     Ability to work collaboratively with staff at all levels.

•     Ability to multitask, prioritize work and adapt to changing priorities.

•     Must be a self-starter and have a strong sense of urgency.

•     Bachelor’s degree or comparable experience in healthcare administration, business, finance, or related field.  A Master’s degree or professional certification (e.g., CPC, CPMA) is a plus.