Manager, Claims Data Operations

Salary Range:  $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.)

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

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

Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.

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 busine