Manager, Coding (Claims Operations)

Manager, CodingMedica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.The Manager, Coding is responsible for the Payment Analytics' and Reimbursement Policy departments to ensure appropriate provider claim payment. The position will include visibility to senior leadership through reporting of results and trending of findings month over month. This position will be responsible for reverse engineering vendor savings, identifying medical cost leakage, share insight and absorb information that may lead to future findings. The duties of this position will have oversight and responsibility for communicating team results and working collaboratively to drive improvements through trending of pre-payment solutions, recoveries, the accuracy of claims payment, volume of claims adjustments, impact to provider service, degree of financial liability, and impact to provider billing pattern changes. This is a working Manager position and may require the candidate to perform, review or summarize audits and includes training incoming staff on audit practices and procedures. Performs other duties as assigned.Key AccountabilitiesRecovery Oversight & Vendor ManagementDevelop a forecast of potential and error savings goals for analyzing claims dataOversee the day-to-day processes used by analysts to perform monthly savings effortsRecover overpayments identified through retrospective data analyticsUncover root cause of errors, influence stakeholders, sponsor process improvement, and continuously enhance claims editing solutionsDevelop and maintain good working relationship with Medica's claim processing vendor to drive ongoing claim policy management to enhance claim processing accuracy and adjustment reductionMaintain up-to-date knowledge of corporate policies, regulatory codes, legislative directive, and other guidelinesSet priorities for staff dedicated to following up on payment integrity leads from vendorsAuditing and ReportingDevelop executive reporting packageComprehend Medica's contracting strategy and how it relates to our provider reimbursement and system capabilitiesReport overpayments or suspected fraudulent behavior to our Special Investigations Unit (SIU)Monitor, manage and report financial impact to managementMaintain reporting structure by ensuring consistency to both internal and external customersImprove processes through automation and/or efficiencies in processReview and analyze team findings on a monthly, quarterly and annual basis to identify trends, areas for focus and improvementAssure processes are auditable (able to be reperformed with a paper/electronic trail)Department RepresentationBe available to internal and external customers as a subject matter expert in the area of waste and errors; and the general processes performed by payment analytics and reimbursement policyEffectively manage and/or participate in projects as assigned by directorEducate and advise customers about the processes, content and trendsAssure integration and collaboration with other Medica stakeholders including pharmacy ops, payment intent/cost containment, network management, SIU, claims operations, operations audit and internal auditDepartment ManagementDevelopment, monitoring and reporting of goals and metrics for analytic identification and reimbursement policy effectivenessAchievement of department production goalsGeneral management duties (coaching, team, staff and 1:1 meetings, issue identification, escalation and resolution, performance measurement)Department recruitment, selection, retention and performance improvement in coordination with department directorPerform annual performance reviewsDevelop and maintain staff morale and promote teamworkProvide recognition to staff through the reward and recognition programsCoach, encourage and facilitate individual growth and development through specific, timely and consistent feedbackProvide technical support to staff by assisting them timely. Guide them to other appropriate resources, if needed.Ensure they receive the training needed to help them be successful in their daily roles as well as provide them opportunities for growthCollaborate with the team to create and maintain department policies, procedures and swim laneAssure processes are established between Medica, post-pay compliance vendors and the claims processing vendorsRequired QualificationsBachelor's degree or equivalent experience in related field7+ years of work experience of progressive experience in claims and coding beyond degree5+ year of people leadership in healthcare operationsPreferred QualificationsStrategic thinker with experience developing metrics, performance measures, and data-driven operational strategiesProven track record of continuous improvement and process optimization in a healthcare or operational environmentStrong analytical skills with the ability to track, trend, and interpret data to identify opportunities and drive business decisionsDemonstrated expertise in issue resolution and root cause analysis, including implementing sustainable corrective actionsExperience influencing cross-functional stakeholders and leading teams to achieve operational and financial objectivesThis position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, St. Louis, MO, or Omaha, NE.The full salary grade for this position is $78,700 - $134,900. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $78,700 - $118,020. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary.Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.