Claims Operations Manager

Description

COMPANY OVERVIEW

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit

SUMMARY DESCRIPTION:

This position has responsibility and accountability for the implementation and ongoing support of Medicare claims operations across the Company. Responsible for ensuring that operational functions are compliant with Centers for Medicare & Medicaid Services (CMS) regulations for Medicare. Demonstrates knowledge of CMS regulations and operational monitoring activities to effectively perform duties that support the Medicare functions delegated by Medicare Advantage (MA) Plans. Demonstrates understanding of operational systems. Ensure that reporting is complete and accurate. Develops and assists in the implementation of operational policies and procedures. Investigates issues and recommends corrective actions as needed, to ensure compliance. Reviews policy and regulatory documents to identify the impact on operations. Responsible for working independently on assigned projects and tasks. Establishes effective relationships across multi-functional groups, providing guidance regarding Medicare Operations.

ESSENTIAL FUNCTIONS:

• Oversee claims production and vendor oversight for Medicare Advantage line of business
• Establish, implement, and provide improvements to internal controls and department policies and procedures
• Maintains knowledge of government regulations as it pertains to claims payments and recognized claims processing standards.
• Investigates and responds to letters of inquiry on claims from members, providers, networks, and government agencies.
• Ensure adequate quality controls and participate with support departments to analyze the root cause of claim payment variations
• Ensure claim support services achieve high provider satisfaction and timely dispute/appeal responsiveness
• Interact with Core Configuration team and vendors to ensure claims systems are robust, compliant and supports business developmental needs
• Helps to coordinate the implementation and maintenance of electronic data interchange (EDI) related to claims submissions and processing status
• Works diligently to ensure accurate claims payment and associated documentation (remits). Identifies trends and resolutions to reduce provider disputes.
• Monitors staff's work regularly for quality and efficiency. Provides training, feedback, coaching, and disciplinary action to staff, if necessary. Supports staff in meeting standards, solving problems, and enhancing performance.
• Works collaboratively with other departments to resolve issues efficiently. Identifies and communicates problems to senior leadership timely.
• Provides support and guidance to Medicare operations to ensure operations are compliant with MA Plan contractual requirements and CMS regulations.
• Monitors day-to-day performance and provide reports to MRx Compliance as required. Participates in ongoing operational and compliance audits. Ensure that reporting is accurate and complete.
• Participates in the planning, development and implementation of new accounts, programs, products and services, initiates and develops short- and long-range plans for department and participates in the development of corporate and strategic plans.
• Participates in implementation of Corrective Action Plans (CAPS).
• Assists Quality Improvement efforts in quarterly audits.

Requirements

POSITION QUALIFICATIONS

Required Qualifications

• Four (4) years minimum in a manager level role or above
• Four (4) years of Medicare claims experience required, and Medicare/DSNP/ACA Exchange operations experience preferred.
• ?Seven (7) years of health plan administration experience