Manager, Claims Operations

Company Description

WHO IS GUIDEHEALTH? 

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. 

Job Description

As the Manager, Claim Operations you will play a key role in Guidehealth’s expansion and growth.  You will provide operational oversight to the claims production and the inventory and reporting teams to ensure all required KPIs and Metrics are being met.  This role will report to the Sr. Director, Claims Operations.

WHAT YOU'LL BE DOING

• Responsible for the day-to-day management of the Claim Operations team.
• Maintains and improves claims processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans.
• Assessing and assigning workflow, coaching, counseling. 
• Use reporting data analytics to track KPIs and report to leadership on a daily, weekly, monthly basis.
• Monitor individual Analysts quality and production measures, conducting staff performance conversations, monthly 1:1’s with individual staff to review their concerns, give feedback, mentor goals and career progression.
• Responsible for writing and maintaining desktop procedures for claims processing functions.
• Identify areas within the claims workflow and system tools where the processes can be improved/enhanced, analyzing current workflows, designing and implementing changes to streamline operations and monitor the impact of those changes to ensure increased efficiency and production.
• Leveraging technological advantages and incorporating new workflows to scale the business.
• Responsible for the distribution and completion of assigned JIRA tickets relating to claims inquiries or adjustments requests.
• Complete first round of claims processing reviews on client reporting requirements prior to sending for their approval.
• Coordinate operational workflows and other internal functions alongside departments and managers.
• Participate in the Monthly Policy and Procedure committee meetings, complete review of policies to approve or suggestions for updates.
• Conduct at minimum monthly team meetings, and attend operational meetings as requested.

Qualifications

WHAT YOU'LL NEED TO HAVE 

• Minimum 3 - 5 years’ experience in Management of a claim operations.
• Demonstrated skill in managing change and in team building
• Advanced knowledge of claims processing including deep knowledge of claims data analysis, and the setting, tracking and reporting on performance metrics.
• Proficient with Microsoft applications, Excel, Word, Access and Power Point.
• Experience with HMO Medical insurance claims with in-depth understanding of federal and state regulations.
• Demonstrated skill in problem solving, exercising initiative, and decision-making within scope of role.
• Thorough understanding of claims processing compliance requirements.
• Ability to meet deadlines and prioritize tasks and assign work daily to the staff. Demonstrated project management experience.
• Ability to work independently with minimal supervision. Exceptional judgement in escalating concerns to next level leadership.
• Exceptional written, visual and verbal communication is necessary to lead a team and convey clear instruction. 
• Change management skills are necessary in order to engage a team as we grow.
• Continuous improvement and a growth mindset are required.
• Claim coding experience, coding edits experience.  
• CPT and ICD coding knowledge and medical terminology

What we’d love for you to have

• Bachelor’s degree in healthcare administration, business, or related field
• Strong understanding of healthcare regulations, insurance contracts, and reimbursement processes.
• Analytical skills with an ability to interpret healthcare data and claims information.
• Certified Professional Biller (CPB), Certified Professional Coder (CPC), or other similar certifications.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
• Claim coding experience, coding edits experience.

Additional Information

The salary for this role is $80,00