Manager, Hospital Claims

1199seiu; New York (NY); On-site; USD 85,000 - 120,000; Full time

Job summary

1199SEIU National Benefit Funds in New York, NY, seeks an experienced Hospital Claims Operations Manager to lead day-to-day processing in the Processor and Clerical Unit. You will supervise staff, direct workload distribution, and ensure accuracy and compliance with SPD guidelines, COB rules, and HIPAA.

The role requires a Bachelor’s degree and at least five years of hospital claims processing experience, including two years in supervision.

Qualifications

• Bachelor’s degree or equivalent years of work experience required.
• Five+ years hospital claims processing, QA, auditing; two+ years supervisor experience.
• Knowledge of CPT, ICD-10, HCPCS, UB-04 and hospital reimbursement methodologies.
• Knowledge of eligibility, medical terminology, COB and third-party reimbursement.
• Basic skills in Word and Excel preferred.
• Strong leadership; independent decision-making, planning, scheduling and reporting.
• Analytical, critical thinking, interpersonal and communication skills.
• Excellent organizational skills; multi-task and meet deadlines.

Responsibilities

• Oversee day-to-day operations of Hospital Claims Department in the Processor and Clerical Unit.
• Provide direction and support to unit leadership in work distribution and audits.
• Ensure timely, accurate processing of hospital claims, emails, and tickets per SPD guidelines and COB rules.
• Manage staff per CBA, assess performance, and coordinate training and QA results.
• Address HIPAA and Compliance standards and corrective actions as needed.
• Monitor QNXT reports, DMS queues, Pend Workflow, and Call Tracking systems.
• Assist in resolving complex issues; release high-dollar claims at appropriate levels.
• Develop policies/procedures and pursue continuous process improvement.
• Collaborate with Care Management, Provider Relations, IT, and vendors to resolve issues.
• Oversee testing related to QNXT upgrades and system enhancements.
• Serve as backup to Assistant Director and QA Manager when needed.

Skills

Leadership

Data reporting

Auditing

CPT/ICD-10/HCPCS

Document management

Decision making

Analytical thinking

Communication

Education

Bachelor’s degree

Tools

Microsoft Word

Microsoft Excel

Job description

Responsibilities

• Responsible for the day-to-day operations of Hospital Claims Department in the Processor and Clerical Unit at the 1199 SEIU National Benefit Funds


• Provide direction and support to the unit Assistant Manager and Supervisors in overseeing work distribution and completion; optimizing workflows; monitoring inventory; responding to audits; compiling production reports; resolving repricing vendor issues; conducting staff coaching and performance reviews


• Ensure timely and accurate processing of hospital claims, correspondence, and Call Tracking tickets according to 1199 Summary Plan Description (SPD) guidelines, member benefits and eligibility parameters, coordination of benefits (COB), regulatory and pre-authorization requirements, Medicare National Correct Coding Initiative (NCCI) rules, ClaimsXten provider and repricing network contract terms and timeframes, and the Fund’s departmental policies


• Manage staff in accordance with departmental, Human Resources guidelines and Collective Bargaining Agreement (CBA) provisions; review and assess staff performance and Quality Assurance audit results; coordinate staff training,


• and take corrective action when necessary to ensure staff meets departmental goals and needs, Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Compliance standards


• Monitor daily QNXT reports, work queue distribution/completion in the Document Management System (DMS), QNXT Pend Workflow, and QNXT Call Tracking systems


• Assist in the resolution of complex and escalated issues; release claims at the high-dollar manager level


• Develop policies and procedures; identify areas of opportunity; engage in continuous process improvement


• Work with Care Management, Provider Relations, Liens, QNXT Production Support, IT, Eligibility, and third-party vendors as needed to resolve outstanding claims issues


• Oversee testing related to QNXT upgrades, system enhancements, and external vendor processes


• Serve as backup to the department’s Assistant Director and Quality Control Reviewer Unit Manager in their absence, to ensure operational activities are achieved and projects are completed


• Prepare and maintain attendance and lateness records; approve weekly payroll timecards


• Participate in provider and third-party vendor conference calls regarding billing/reimbursement issues and trends, as well as Contract Interpretation and Joint Operating Committee meetings


• Perform additional duties and projects as assigned by management

Qualifications

• Bachelor’s Degree or equivalent years of work experience required


• Minimum of five (5) years hospital claims processing, quality assurance, auditing experience required; to include a minimum of two (2) years supervisor experience


• Strong knowledge of CPT, ICD-10, HCPCS, UB-04 and hospital reimbursement methodologies; good understanding of hospital contracts


• Knowledge of eligibility, medical terminology, third-party reimbursement and COB


• Basic skill level in Microsoft Word and Excel preferred


• Strong leadership skills required; able to make independent decisions concerning management, planning, scheduling, and assignment of work; excellent time management and data reporting skills


• Strong analytical, critical thinking, interpersonal and communication skills (written and oral)


• Excellent organizational skills; able to multi-task, work well under pressure, prioritize and follow up