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Director of Claims-International Claims Management

Primary Role & Responsibilities:

  • Provides leadership, development and mentoring of the Claims Management and staff by creating a culture of high performance that is driven by strategic objectives, service excellence and the company’s goals
  • Responsible for directing the planning, design, development, implementation and evaluation of policies and procedures that assure accurate, timely claims processing and provider inquiries (written or verbal)
  • Oversees vendor relationships pertaining to Claims processes (i.e. Com-Com)  
  • Generates data in order to track and report on results compared to operational and service level goals and other trends as required
  • Creates and manages departmental budget and meets financial targets
  • Maintains confidentiality of all patient information, as per HIPAA guidelines
  • Analyzes, tracks and trends claims data in order to provide analysis of data / results along with action steps to ensure operational efficiencies are maintained

Claims Adjudicator Duties/Skills:

  • Generates standard reports for the functional area and tracks all employee performance for high volume transaction area
  • Oversees day to day employee metrics and Claims to Work performance
  • Conducts auditing on claim adjudication activities
  • Evaluates adjusted claims against original claim processing activities to identify processing errors undetected during initial processing
  • Provides input into adjudication materials and their revisions to ensure quality outcomes during auto and manual adjudication
  • Conducts adjudicator audits of processed claims against guidelines, policies and procedures

Minimum Knowledge, Skills and Abilities:

  • Prior experience in healthcare and insurance field for processing international medical claims. Experienced with UB’s & HCFA’s as well as superbills.
  • Minimum of a BA/BS degree with at least five (5) years of relevant professional experience, and the following:
  • Strong knowledge of medical coding (ICD-9, ICD-10, CPT)
  • Maintains current knowledge of coding issues which includes accurately coding within CMS and carrier compliance guidelines, laws and policies from CPT, HCPCS and ICD-9/ICD-10 coding manuals.
  • Previous Adjudication or Claims Adjusters License is a plus
  • Extensive knowledge of claims policies and procedure
  • Experience in developing and tracking performance metrics
  • Experience with managing US & International Claims
  • Experience working with large US/International carries in a similar role
  • Experience with Fraud, Waste & Abuse
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