Manager, Claims & Remittance – Managed Care

Requisition # HRC0932404

The Manager, MN Claims & Remittance is responsible for Claims Production Department by supervising the activities of Claims Supervisors, Claims Examiners and other department staff in managing the timely and accurate adjudication of claims through the administration of departmental policies and procedures and regulatory standards.

Job Duties & Responsibilities:

• Is responsible for Claims Production activity and to ensure the timely and accurate adjudication of claims in accordance with standard claims processing procedures, departmental policies and procedures, and regulatory standards.
• Is responsible for the ongoing monitoring and tracking of Claims Department inventory and adherence to the goals for claims inventory.
• Monitors Claims Production using TAT reports, Production reports, and Denial Letter process.
• Monitors Mailroom operations to ensure timely and accurate processing of batches, sorting of claims and correspondence, inventory levels, misdirected claims forwarding, and mail-back process.
• Ensures follow-up on suspense and error reports to ensure that pending claims meets department turn-around times.
• Works with other departments to implement and maintain products and client services.
• Is part of administrative meetings and disseminates information to staff, when appropriate.
• Provides mentorship and training to department staff to ensure that department standards, procedures and regulatory standards are met.

Education:

High school diploma/GED required.

Experience:

Five (5) years of experience in Claims Remittance or related field required.

Eight (8) years of experience in claims operations specifically related to managed care in a complex and diversified healthcare or health insurance company preferred.

Solid understanding of provider network/IPA arrangements and reimbursement methodologies and of health benefit plan concepts such as limitations, exclusions, carve-outs, coordination of benefits, benefit accumulators, member and plan responsibilities, authorization requirements, recoveries, and the appeals process.

Vast knowledge of physician and facility billing practices, appropriate CPT coding initiatives, ICD-9/ICD-10 coding standards related to specificity, as well as Revenue and HCPCS coding.

Conversant with standard electronic and paper claim formats; knowledge of American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) coding guidelines such as the National Correct Coding Initiative (NCCI) edits and their relation to clinical logic in claims adjudication

Experience with all regulatory standards such as HIPAA, DMHC, AB1455, and CMS reporting requirements.

Extensive knowledge of one or more of the following managed care transaction systems: EPIC (Tapestry Module); Working experience with claims edit software (i.e. Optum CES, McKesson etc.).

Working Title:

Manager, Claims & Remittance – Managed Care

Department:

MNS – Managed Care

Business Entity:

Medical Network

Job Category:

,Clinical Operations,Clinical Operations

Job Specialty:

Clinical Operations

Position Type:

Full-time

Shift Length:

8 hour shift

Shift Type:

Day

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.

Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.

At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu) and COVID-19. For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy.

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