Manager, Claims and Payment Integrity

Longevity Health is growing rapidly and is looking to add new talent to our team. Longevity Health Plan currently has operations in Colorado, Florida, Georgia, Illinois, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, and Texas, with plans to start-up operations in other states in the very near future. Due to our rapid growth, we have an immediate need for a Manager, Claims and Payment Integrity.

General Purpose: The individual holding this position is required to support and demonstrate their commitment to the Longevity Health Plan Statement of Purpose, which is: To improve the health and quality of life of nursing home residents by caring for their unique medical, social and emotional needs

The Claims Manager performs day to day duties to assure accurate payment of claims and capitation. The Claims Manager is responsible for tracking claims inventory, including aging and working with a TPA to ensure accurate and timely processing of claims. Act as a liaison between providers with TPA, claims and capitation issues, Market Presidents, Account Managers, and Corporate, including investigation and resolution of claim issues. The positions scope incorporates internal and external responsibilities.

Key Tasks and Responsibilities:

Create weekly reports to track, trend and prevent claim overpayments.
Responsible to maintaining claim reporting that includes claim composition, aging, and provider trends.
Reviews claim metric requirements and ensures the TPA hits minimum metrics (timeliness, processing accuracy, etc.).
Works with the TPA to ensure authorization coding requirements are loaded – tests configuration as needed.
Coordinate operational and administrative activities associated with claims processing accuracy.
Work closely with the Provider Network Department as issues arise.
Attend Ad-hoc meetings to discuss claims payment discrepancies.
Prepare and review and analyze the accuracy of pre-payment reports.
Audit paid claims to determine areas for improvement.
Assist with processing of monthly capitation to providers.
Establish professional relationships with providers to research their issues and ensure all are addressed timely and accurately.
Work with the TPA system to run reports, validate information from the claims system and respond to queries from senior management.
Establish quality control processes for documentation of payment accuracy.
Respond to incident tickets within SLAs.
Work closely with the Finance Team to coordinate/review/confirm payments.
Establish a professional relationship with outsourced entities.
Coordinate special projects as assigned.
Support organization's strict adherence to the Company's Compliance Plan and Standards of Conduct with emphasis on compliance with established procedures and protocol, internal controls, and maintaining the highest level of workplace behavior.
Provide oversight to high dollar claims review process – both pre and post pay.
Performs other related duties as assigned.

Licensure:

There are no licensure requirements for this position.

Education and Training:

High school diploma or equivalent required.

Knowledge and Experience:

5 years claims processing in a Medicare environment.
Knowledge of CCI Edits and CMS guidelines.
Understanding of different claims payment methods including professional vs institutional, DRG capitation.
Strong technical, analytical, and trouble-shooting skills.
Excellent follow-through skills; self-motivated, and detail oriented.
Strong organizational skills to manage multiple projects, issues, and priorities effectively and simultaneously, with attention to detail.
Intermediate to Expert level proficiency in the MS Office Suite (MS Word, Excel, and Outlook).

Company Overview:

Founded in 2018, Longevity Health started as an Institutional Special Needs Plan (ISNP), a type of Medicare Advantage health plan that addresses significant unmet needs of long-term institutionalized members who reside in nursing homes. Through rapid growth from 2018 to 2022, we expanded our market footprint and currently offer ISNP Medicare Advantage plans in Colorado, Florida, Illinois, Michigan, New Jersey, New York, and North Carolina.

In 2023, we expanded our service offerings to the broader health plan market. In addition to our existing markets where we are both the ISNP and the care management team, we are now partnering with National Carriers on their offered ISNP plans in Ohio, Pennsylvania, upstate New York, Georgia, South Carolina, and Texas, with implementations in progress for several other additional US states. This allows us to utilize our core skills of supporting clinical post-acute needs of this vulnerable senior population Currently 13 markets and expanding rapidly.

Company Disclaimers:

Longevity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

It is the policy of Longevity Health to follow Federal and / or State regulations surrounding COVID vaccinations. While CMS guidelines have been relaxed, there are some LHP facilities which will still require staff be vaccinated in an effort to protect the health of the members / patients we serve. If your assigned location(s) require all staff to be fully vaccinated, you are required to obtain and / or provide documentation related to your COVID vaccination. To confirm whether your assigned location(s) require COVID vaccinations, please refer to the Facility Guide Job Aid located on Longevity Health Plan’s intranet site.

The Company will engage in an interactive process with individuals who cannot be vaccinated for medical or sincerely held religious beliefs to determine if a reasonable accommodation can be made. While an exemption/accommodation may be initially granted, if at any time during employment, it is determined that an exemption/accommodation that has been granted is no longer considered a reasonable accommodation, it can result in employment with the Company ending.

Candidates must meet the Company’s hiring criteria which include a pre-employment background and drug screening.

Longevity Health offers a competitive compensation and benefits package which includes medical, dental, vision, short and long-term disability, life insurance, and 401(k).

Submission of false information during the application process may result in immediate termination of employment without notice.