Manager, Claims Operations

Manager, Claims Operations

Reporting to Director, Claims, the Manager, Claims Operations is responsible for the performance of the San Francisco Health Plan (SFHP) Claims Department. You will ensure compliance with all regulatory and contractual requirements related to claims processing. Main duties include managing Claims staff performance, morale, training, and skill development. Additionally, you will provide metrics, overseeing workforce allocation and analysis, and participating in audits to ensure resolution of all corrective action plan (CAP) items. Furthermore, you will create, distributing, and enforcing policies, procedures, and desk guidelines.

Please note that while SFHP supports a hybrid work environment, you are required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $140,000 - $150,000 per year

What You Will Do:

• Lead and manage claim operations, including first pass claims processing, recoveries, provider disputes (PDR), payment integrity and overall performance of the SFHP Claims Department. Build and develop teams into cohesive units.
• Ensure compliance following all regulatory and contractual requirements.
• Motivate Claims staff and take necessary steps to ensure service is always provided to both internal and external customers.
• To ensure accurate claims payment, documentation and remittances. Monitor aging and accuracy of paid claims to ensure departmental metrics are met.
• Identify, implement and monitor appropriate performance metrics aligned with SFHP organizational goals and objectives. Take appropriate action when metrics are out of performance thresholds.
• Prepare, analyze and act upon claims statistics, reimbursement trends and team performance metrics.
• Ensure that all claims are processed accurately and efficiently following SFHP policies, processes and procedures.
• Ensure timely, accurate and thorough responses are given to all provider dispute requests (PDR) and inquiries regarding claims status and other claims information in compliance with regulatory requirements. Identify trends and resolutions to reduce PDR.
• Ensure communication with all internal and external stakeholders.
• Meet with other departments that impact Claims to resolve problems.
• Demonstrate ability to determine root cause of issues to create appropriate solutions.
• Work with appropriate technical staff to design, develop, enhance, modify and utilize claims data reporting tools. Provide SFHP management with trend analysis and other analyses.
• Work with appropriate technical staff to design, configure and test modifications to claims adjudication software and ancillary systems. Work with main staff to research, report and resolve any routine problems with claims payment processes.
• Monitor and evaluate staff performance, attendance and punctuality. Provide ongoing, constructive and objective performance feedback. Take corrective action promptly when inappropriate behavior and/or performance related problems arise to foster improved performance and early problem resolution.
• Oversee and develop staff to achieve mastery in their current roles and cultivate them for more advanced roles in the organization.
• Hire and train new team members properly. Take steps to distinguish and ensure acknowledgment and retention of high performers.
• Direct and manage internal or interdepartmental projects.
• Manage department budget.
• Lead department participation in all regulatory and financial audits, including resolutions of audit findings.
• Update existing policies, desktop procedures, Claims Operations Manual and other documentation promptly. Create new policies and procedures.
• Define internal department audit requirements based on results on monthly random audit, Contract and Compliance audits and external audits.
• Oversee claims user acceptance testing for projects and system changes to ensure they are completed thoroughly.

What You Will Bring:

• Bachelor's degree in a related area or equivalent work experience required
• Four years of prior relevant management experience
• Five years working experience in a health care environment, preferably in managed care, Medi-Cal, Medicare or other government program
• Experience handling PDRs
• Demonstrated experience in medical claims procedures, processes, governing rules and all aspects of claims adjudication
• Expertise in standard claims processing systems and claims data analysis
• Working knowledge of claims coding and medical terminology

What We Offer:

• Health Benefits
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.

About SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.