Claims Team Manager II, Medical Stop Loss
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Under limited direction from the product line Claims Manager, manages a team of individual contributors handling claims in Medical Stop Loss, including HMO RE/Provider Excess and Employer Stop Loss (direct and Program) product lines within IronHealth. Responsible for oversight of claims handled within the team and supervision of claim professionals directly reporting to this position. Has distinct accountability for business results for assigned claims team and has administrative accountability for lower level claims staff.
- Responsible for assisting the Vice President of MSL Claims with managing the MSL Claims Staff, process workflow, claim inventory and turn-around time, claim appeals, follow up of pended claims, and the year-end reconciliation of all policies.
- Responsible for performing quality reviews, assisting with the monthly reserve review, and the review and preparation of the monthly Excess Reports.
- Responsible for reviewing and approving claims over the authority limits of the Claim Specialists and Senior Claim Specialists, which entails examining, evaluating, and determining eligibility of claims on a timely basis by applying the appropriate contractual provisions to the facts and specifications of the claims.
- Accountable for interpreting contracts, issuing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss/Excess Loss/HMO Re/Provider Excess claim determinations.
- Responsible for maintaining customer relations and the financial risk associated with managing claims. This requires applying the appropriate contractual policy provisions and the plan specifications of the underlying plan document, seeking professional case management resources when necessary, following standard claim practices, procedures and protocols to the facts of each claim to decide on reimbursement/denial of a claim.
- Must have the ability to interpret and apply the appropriate provisions from both the underlying plan document of the policyholder, as well as the Stop Loss, HMO RE, or PEI contract, especially regarding eligibility and exclusions.
- Responsible for preparing written rationale of claim decisions based on the review of the contractual provisions and plan specifications, and the analysis of the claim/medical records.
- Must consistently meet departmental standards for productivity and quality, and have an awareness of industry claim practices, including, but not limited to, knowledge of legal risk and regulatory/statutory guidelines, HIPAA privacy, Affordable Health Care Act, etc.
- Must be able to understand where, when, and how professional resources (e.g., medical, investigative, and legal), both internal and external, can add value to the process.
- Must maintain cooperative and productive relationships with fellow claim staff members and other company departments.
- Individual may be asked to perform other duties, as needed and as assigned.
- 5-10 or more years of experience with handling/reviewing/processing medical claims and/or medical stop loss claims and 1+ years' experience, preferred, managing/supervising claims staff, including, but not limited to, claim analysts/examiners and claim support staff. With no supervisory/managerial experience, 10-15 claims handling experience is required.
- Advanced knowledge of common medical terminology, diseases and their related risks, and all types of claim coding.
- Knowledge and experience with one of the following product lines is required: Employer Stop Loss, Excess Loss, HMO Re, or Provider Excess Insurance claims. Knowledge and experience with all those lines of business is preferred.
- Must demonstrate the ability for success in negotiation, persuasion, solutions-based claim paying, and claim supervision.
- Must have the ability to work in a fast-paced environment and the flexibility to handle multiple priorities, while maintaining a high level of professionalism.
- Must have strong oral/written communications and analytical skills, as well as be proficient with Excel and Word programs. Experience with the David Young System (DYS) is a plus.