Manager, Medical Claims Resolution Department

About the position

The Manager of the Medical Claims Resolution Department at WellMed, part of the Optum family, is responsible for overseeing the daily operations and inventory management of the claims resolution department. This role focuses on ensuring timely resolution of provider claims while collaborating with the Utilization Review Department. The Manager will supervise MCR supervisors, provide guidance, and ensure compliance with regulatory and health plan requirements, all while fostering a collaborative and inclusive work environment.

Responsibilities
? Develop and implement departmental processes to ensure compliance with contractual, federal, and state guidelines related to claims resolution and utilization review
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? Oversee the quality assurance process for the resolution of claims, ensuring timely and accurate handling of claims and responses in collaboration with the Utilization Review Department
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? Continuously assess the staffing needs of the department based on workload and production goals, making adjustments as necessary to maintain compliance
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? Establish production and quality goals for each function within the department and monitor and track performance
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? Respond to compliance audits for claims resolution to track regulatory compliance and provide management reporting
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? Serve as a resource to departmental supervisors and staff for questions related to contractual interpretation, process administration guidelines, workflow, and operational issues
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? Act as a liaison for communication with other departments, including the Utilization Review Department, business associates, health plan partners, and state and federal entities
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? Manage and coordinate any testing required for changes or upgrades to the claims resolution platform
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? Participate and collaborate with internal teams associated with Network Operations and external departments within WellMed
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? Stay informed about new and pending legislation that may impact the guidelines followed by Third Party Administrators related to claims resolution and utilization review
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? Perform any other related duties as assigned

Requirements
? High School Diploma / GED OR equivalent work experience
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? Must be 18 years of age OR older
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? 5+ years of experience with claims resolution and utilization review in a managed care setting
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? 3+ years of experience in a lead OR supervisory capacity
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? Knowledge of federal and state laws regarding claims resolution and utilization review
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? Proficiency in Microsoft Office programs, including Microsoft Word, Microsoft Excel, Microsoft Outlook, Microsoft Access, and Microsoft PowerPoint
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? Ability to work Monday - Friday, during our normal business hours of 7:00am - 4:00pm

Nice-to-haves

Benefits
? 1-3 months of on-the-job training
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? Flexible work from home and office in a hybrid role
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? Opportunities for career development and advancement

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