Manager, Hospital Claims

1199SEIU Benefit and Pension Funds; New York (NY); Hybrid; USD 90,000 - 130,000; Full time

Job summary

1199SEIU Benefit and Pension Funds in New York, NY, seeks an experienced Hospital Claims Department Leader to oversee the Processor and Clerical Unit. You will manage workflows, supervise staff, and ensure accurate processing of hospital claims, SPD-compliant documentation, and referrals across COB and pre-authorization rules.

You will collaborate with Care Management, Provider Relations, IT, and third-party vendors, drive process improvements, mentor staff, and ensure HIPAA and internal

Qualifications

• Bachelor's degree or equivalent years of work experience.
• Minimum of five (5) years hospital claims processing, quality assurance, auditing experience; at least two (2) years in a supervisory role.
• Strong knowledge of CPT, ICD-10, HCPCS, UB-04 and hospital reimbursement methodologies; solid contract understanding.
• Knowledge of eligibility, medical terminology, COB and third-party reimbursement.
• Proficient in Word and Excel; able to manage data and generate reports.

Responsibilities

• Responsible for day-to-day operations of Hospital Claims Department in the Processor and Clerical Unit.
• Provide direction and support to Assistant Manager and Supervisors; optimize workflows and monitor performance.
• Ensure timely and accurate processing of hospital claims, correspondence, and Call Tracking tickets per SPD guidelines and COB requirements.
• Manage staff per HR guidelines and CBA provisions; review performance and QA audit results; coordinate training.
• Monitor QNXT reports and DMS/Call Tracking systems; resolve escalated issues; release high-dollar claims.
• Develop policies and procedures; pursue continuous process improvements; coordinate with Care Management and IT to resolve issues.
• Oversee testing related to QNXT upgrades and external vendor processes; backup for Assistant Director and Unit Manager when needed.
• Prepare attendance/late records; approve payroll; participate in vendor calls and Joint Operating Committee meetings.

Skills

Leadership

Analytical skills

Communication skills

Time management

Education

Bachelor's degree or equivalent

Tools

Microsoft Word

Microsoft Excel

Job description

• 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

• Requisition #: 7510
• # of openings: 1
• Employment Type: Full time
• Position Status: Permanent
• Category: Non-Bargaining
• Workplace Arrangement: Hybrid
• Fund: 1199SEIU National Benefit Fund
• Job Classification: Exempt

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