Manager, Claims - Amalgamated Life

Overview

The Manager of claims is responsible for the direct supervision of the Claims Analysts and other assigned staff, and oversees all claim processing related activities and functions, including monitoring inventory, production, quality, as well as provide guidance to examiners on claims related questions and issues.   

Responsibilities

• Oversees the administration of the assigned claims processing unit, including all functions and processes required to process medical, hospital, vision, dental and other claim types.   
• Performs personnel and job supervisory duties required to ensure that staff is meeting performance goals; conducts mid/annual performance reviews; confirms production incentive; monitors employee attendance and lateness.   
• Monitors individual analyst production and quality providing feedback, support, and instruction to assist staff with meeting goals.  
• Manages claims inventory via Workflow with a goal of meeting required JAA and DOL turnaround time requirements.  
• Provides daily guidance and technical instruction to the claims staff, ensuring that claims are handled timely and appropriately.  
• Identifies training needs and provides necessary training, including refresher to direct personnel.  
• Works with quality assurance department to provide feedback and corrective action on claims quality.  
• Must possess a working knowledge of all plans for which he/she is responsible and keeps up to date on any benefit plan and procedural changes and communicates with staff.  
• Oversees the claims correspondence Workflow to assign correspondences to examiners for timely review and adjustment of affected claims within DOL/JAA timeframes; prepares responses if needed.  
• Interfaces with AMCM or external vendors on medical claim referrals and any pre-certification issues.  
• Consults with appropriate personnel throughout the company or external vendors/clients to obtain information required to resolve and process claims. 
• Maintains knowledge of eligibility requirements and understands the complexities of the system interfaces.  
• Monitors and oversees the correct handling of high dollar claims ensuring timeliness of handling; reviews, examines, and directs processing of unusual or difficult claims.   
• Oversees the Anthem JAA mailbox/portal /and medical records to ensure timely response and handling.  
• Oversees the review, distribution, and response to Customer Service and service/account rep referrals/ inquires using Salesforce or any current system in use for communicating with Customer service.  
• Handles various assignments or projects, as needed. 
• Provide support to other claims departments as is necessary. 
• Escalates any and all claims issues that are adverse to the overall departmental claims department quality.   
• Attend Client board meetings, as necessary. 

Qualifications

• Bachelor's or associate degree preferred. 
• Supervisory or related experience preferred.  
• Five or more years work experience in handling health insurance or self-funded claims.  
• NYS A&H Adjuster license (to be obtained within 3 months of employment) 
• Familiarity with industry terminology and claim related medical terminology.  
•  High level of organizational and problem-solving skills. 
• Excellent written and verbal communication skills. 
• Team player and willing to collaborate with management team. 
• Good computer skills, including use of MS Word and Excel.  

70-80K