Manager, Commercial Claims - Peak Health

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full.  Below, you’ll find other important information about this position. 

Come join WVU Medicine to help design and build a health plan from the ground up as Manager, Claims. Experience in the industry and critical thinking skills will help the organization build an effective and efficient Claims function. Reporting to the Director, Claims Operations, this role will be a critical part of our leadership team.
Timely and accurate claims processing is a critical capability this position will need to build as the organization creates the health plan operations. The Manager will be an integral part of the organization’s success as this role and others in the plan work together to create and execute on a vision for our Claims team. The Manager will also partner with IT and other business leaders to ensure the deployment of our core administration platform is consistent with Claims requirements the Manager and team develop.
Once operational, the Claims team will review and oversee the adjudication of claims ranging from the simple to complex specialty claims. The Manager will help develop prescribed guidelines and procedures; use independent judgment requiring analysis of variable factors to solve problems; collaborate with management and top professionals/specialists to implement solutions. Each day the Manager and team will determine whether to return, deny, or pay claims following organizational policies and procedures. The Manager will promote a culture of collaboration, empowerment and accountability while ensuring our Claims function meets operational objectives.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, EXPERIENCE, AND/OR LICENSURE:

1. Bachelor’s degree Business Administration, Health Administration or related field AND Five (5) years of progressive experience working with medical or institutional claims in a production environment OR;

High School Diploma or equivalent AND Nine (9) years of progressive experience working with medical or institutional claims in a production environment.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Two (2) years of experience working with Medicare and/or Medicaid claims.

2.Three (3) years of management experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Designs, builds and maintains operational processes, policies and procedures to support Claims processing.

2. Partners with IT and other leaders to develop business requirements to support core administration system deployment.

3. Recruits, trains and develops a highly engaged team of claims processors.

4. Claims inventory management and load balancing to meet contractual and organizational objectives.

5. Anticipates future demands of initiatives related to people, process and technology and works with leadership to design and implement solutions to these needs.

6. Collaborates with IT, Enrollment, Medical Management, Member & Provider Services and Finance to identify and implement processes to drive continuous improvement.

7. Continually assesses activities and processes to ensure efficiency and added value.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Strategic thinking and planning.

2. Ability to execute.

3. Strong business acumen including technical knowledge of claims system, and authorization systems.

4. Ability to work across business and technical requirements to support execution of technology initiatives.

5. Excellent communication and collaboration skills.

6. Attention to detail.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2902 PHH Claims Operations