MEDICAL CLAIMS MANAGER

Job Description

Job Description

Description:

SEIU Healthcare IL Benefit Funds is a dynamic benefits administration organization committed to providing the highest quality health and retirement benefits in the most financially responsible manner, while always acting in the best interest of the union members. The Fund serves over 20,000 union workers in the Nursing Home, Home Care, Child Care and Personal Assistant industries with the delivery of health and pension benefits. Our 50+ employees epitomize the Fund’s core values of quality service, interdependence, effectiveness, and accountability, and forge an alliance with one another to carry out our shared mission and common agreements for those we serve.

Position Summary:

The Claims Manager is responsible for overseeing the daily operations of the Claims Department. The Claims Manager leads the claims staff by effectively applying technical competencies and leadership strategies to oversee employee management and ensure the team meets all departmental policies, procedures and performance goals of the medical claims processing operations. The work will focus primarily on effective supervision of staff, end-to-end claim processing automation and optimization, and claims system configuration. The Claims Manager will coordinate initiatives and priorities with other leaders and departments, requiring a high proficiency of both collaboration and independent work to ensure plan participants and medical providers are being serviced with high-quality standards in a timely manner.

The Claims Manager will maintain a high standard of performance while identifying problems, developing solutions and process improvements, and resolving issues with direct reports and other stakeholders. This position reports directly to the Deputy Administrator, and provides collaborative support to all levels of leadership and staff.

The Claims Manager will be responsible for the following:

Key Duties and Responsibilities:

• Oversee immediate direct reports in key functional areas including claims inventory and processing, production standards, system configuration, plan network development, vendor relations and interdepartmental processes and procedures.
• Establish and monitor key performance indicators (KPIs) to track trends and progress of department goals and objectives; and the quality of work performed by employees in the pursuit of achieving goals and objectives and quality, productivity, and compliance standards.
• Establish, assign, distribute, and monitor quality and quantity metrics to ensure all production standards are understood and met by employees and inventory levels are managed to meet processing timelines.
• Ensure compliance and regulatory guidelines of multiemployer Taft-Hartley trust funds are adhered to, including but not limited to PPACA, CAA (No Surprises Act and Transparency Rules), DOL, ERISA, HIPAA, and other required guidelines.
• Maintain knowledge of all Fund health plans and department operations.
• Oversee the maintenance of plan documents, including but not limited to summary plan descriptions (SPD), summary of material modifications (SMM), and summary of benefits and coverage (SBC).
• Triage and/or resolve escalated inquiries in a timely fashion from plan participants, unions, medical providers and/or billers.
• Report on cost and performance outcomes of medical home plans, plan networks, disease management programs, and medical benefit initiatives while providing recommendations to enhance offerings to plan participants and manage medical costs.
• Identify issues and problems, develop solutions, and prepare recommendations, including process improvements and enhancements of policies and procedures.
• Assign, oversee and approve the development of departmental policies and procedures for consistency in claims processing operations.
• Ensure the active operation and optimization of a benefits administration system(s) that fully supports the functions of the department.
• Support the compilation and reporting of claims data to be analyzed and used for contracting, medical cost management, benefit improvement, disease management, vendor management, and member and provider relations initiatives.
• Configure contract terms within the benefits administration system to ensure accurate payments are processed and reflected in the participant and provider explanation of benefits (EOBs, EOPs).
• Communicate professionally to develop and maintain effective working relationships with internal leadership and staff, and external stakeholders and partners as directed, including but not limited to plan participants, medical providers, trustees, government agencies, unions, members, attorneys, and consultants.
• Attend, facilitate, and/or participate in various meetings, including weekly leadership, department, one-on-one with staff, and technology related meetings, All Staff meetings, and assigned committee, training sessions, task force, and other meetings as deemed appropriate to share, discuss, and solution for issues, as well as identify potential process improvements.
• Create agendas for all pre-scheduled meetings using the Purpose, Outcome, and Process (POP) Model and require distribution of thorough notes for each meeting.
• Cultivate an environment of high morale, performance, empowerment, continuous improvement, innovation, team engagement and initiative.
• Ensure proper and timely dissemination of all process, procedural and business updates to the team and interdepartmentally based on member and organizational requirements.
• Maintain knowledge of State and Federal regulations, implementing best practices and changes regarding claims and billing requirements to achieve continuous improvement and productivity standards.
• Perform other similar related duties, special projects, and multiple tasks as required.

Employee Relations

• Meet weekly with staff to build relationships, review operational processes, provide performance progress, employee coaching, and feedback, at the department level and one-on-one.
• Accurate and timely review and approval of time off requests and bi-weekly payroll processing for direct reports.
• Direct supervision of Medical Claims staff; consult with the Deputy Administrator and Human Resources in the employment lifecycle of direct reports.
• Prepare and conduct timely annual employee performance evaluations.
• Respond consistently, timely, and accurately to employee questions, issues, concerns, performance reviews, and feedback, referencing guidelines outlined in the employee manual, CBA, and/or other policies and procedures.
• Enforce adherence of and compliance with written personnel policies, procedures, and communications approved by executive leadership.
• Deliver regular and timely coaching and feedback with departmental staff on navigating departmental challenges, employee engagement, skills training and career development, employee discipline, and performance improvement.
• Provide mentorship and guidance to department staff to ensure retention of high performing and motivated employees who meet performance benchmarks, align with the organizational mission and processes to achieve shared goals, and have training and development opportunities.
• Work closely in a collaborative team approach with Deputy Administrator and Human Resources on personnel and career development matters, timelines, goals, workforce readiness and stabilization, and succession planning.

Privacy and Security Responsibilities:

This position requires the handling of Personal Identifiable Information (PII) and potentially Protected Health Information (PHI) for our members. You will be responsible and accountable for maintaining the confidentiality, integrity, and availability of all PII and PHI. Report any suspected identity or HIPAA violation or breach to our HIPAA Privacy and Security Officer.

Requirements:

Desired Qualifications, Experience, and Characteristics:

• 7+ years of experience working in a Taft-Hartley environment, benefit administration, third party administrator (TPA), managed care, self-insured plans, non-profit, labor unions, movement building, and/or mission-driven organizations.
• 4+ years of managerial experience, preferably in medical insurance, medical claims or healthcare billing operations, benefits administration, or third-party administration.
• Bachelor’s degree required, in business management, healthcare administration, or other relevant fields.
• An equivalent combination of education, certification, training and/or work experience may be used to meet the minimum education qualifications.
• Demonstrated leadership knowledge, skills, experience, and the implementation of best practices, with a familiarity of healthcare, social-economic and labor movements, and political issues that impact the organization.
• Demonstrated professional accountability and practiced use of self, with the commitment to manage up, laterally, and to direct reports in a collaborative manner.
• Excellent written, verbal, and non-verbal communication and interpersonal skills to clearly articulate and share meaning of complex issues to a wide variety of audiences including peers, staff, leaders, and internal and external stakeholders and partners.
• Demonstrated knowledge and experience working with contracts.
• Experience in methods analysis and work simplification to enhance operational efficiencies.
• Ability to collect, research, and synthesize complex information to provide data-informed recommendations in detailed reports for leadership, with a keen sense of insight and experience to complement the data.
• Excellent organizational and time-management skills, with demonstrated experience developing and implementing individual and group timelines in a changing and emergent environment to successfully meet established goals, objectives, and timelines.
• An accomplished and agile change management leader with proven experience demonstrating resiliency to setbacks and applying strong analytical skills and discernment toward problem/issue identification and resolution.
• Demonstrated record of accomplishment leading and working with organizations that center and value diversity, equity, inclusion and belonging while advocating for human and technical systems that support racial, gender and socio-economic equality and justice in the workplace.

Personal Characteristics

• A passionate commitment to the Mission, Vision, and Core Values of the SEIU Healthcare IL Benefit Funds.
• A sense of grace and humor in the face of challenges.
• Demonstrated creative innovation to advance and align organization culture, structure, and skills.
• An exceptional team spirit and positive attitude, along with a high degree of integrity and judgment to earn and maintain employee and team confidence, morale and engagement.

Technical Experience

• Strong knowledge of industry standard medical coding, including ICD-10 diagnosis codes, CPT procedure codes, HCPC codes, HCFA 1500 and UB-02 claims forms; and in-depth claims processing, billing analysis, subrogation, medical and pharmacy benefits expertise.
• Advanced user of benefits administration software, Basys/Bridgeway preferred.
• Intermediate user of project management tools, Smartsheet preferred.
• Experienced leadership in a hybrid work model, providing in-person support and reliable remote work output and relationship building.
• Technical facilitation and meeting moderation in a variety of virtual conference platform settings and in-person.
• Intermediate to advanced skill level, using Microsoft Office Suite (Word, Excel, Outlook, and Power Point).
• Knowledgeable use of printers, copiers, scanners, fax machines, and other office equipment.

Career Development & Continuing Education Opportunities: Yes

Benefits:

SEIU Healthcare IL Benefit Funds offers a comprehensive health benefit (medical, dental and vision coverage) for employees and eligible dependents, including no employee premium option for employee only; competitive compensation; generous holidays and PTO policies; and a pension retirement plan.