Claims Provider Data Oversight Manager

Job Summary:

The Claims Provider Data Oversight Manager oversees and manages the enhancement of claim outcomes across existing and emerging lines of business within the Claims organization. Responsibilities include orchestrating collaborative efforts with cross-functional teams to devise and implement project strategies, mitigate risks, monitor progress, lead process optimization endeavors, and create transformative change.

Expert-level comprehension of Facets and provider data with a deep understanding on the impact to the end-to-end claims process from intake to remittance, and exceptional communication and interpersonal abilities are imperative for success.

Essential Functions:

Define and influence the functional requirements of provider matching logic, Facets claim adjudication procedures, provider data load and management requirements, provider configuration, and claims end-to-end adjudication processes

Collaboratively influence claim intake, provider match logic, pre-adjudication, adjudication, post-adjudication, payment procedure, and provider data management

Facilitate business requirements to technical solutions with business teams and technical teams for seamless alignment

Partner with the Provider Data Management team to influence provider data loads;  collaborate with business, architecture, and infrastructure units to uphold exceptional service levels and bolster stakeholder satisfaction

• Lead the seamless implementation of provider data management to ensure appropriate claim outcomes for new and existing lines of business within the Claims organization
• Identify future system enhancements, provider matching logic opportunities, data migration requirements  and perform end-to-end testing, when applicable
• Perform detailed analysis of data, workflows, policies, procedures, and offer potential solutions to execute growth initiatives

Oversee the analysis of provider data management processes and influence and develop functional requirements, document and communicate captured information for validation and re-usability

Conduct intricate data analysis, workflow evaluations, and policy assessments to propose and execute initiatives aimed at refining provider data loads, operational efficiency and resolving complex technology and process-based challenges

Organize work teams, drive consensus, and ensure end-to-end policy and process integrity to accomplish project work, including stakeholder participation; establishment of a project plan; meeting facilitation; consensus building; recommendation and decision documentation for all claim outcomes driven by provider data management oversight

Stay abreast and ensure adherence of industry best practices and regulatory mandates, integrating them into claims and provider data management processes relative to claims outcomes

Ensure compliance with regulatory and contract obligations in new business implementations

Foster a culture of continuous improvement, contributing to the development and enhancement of provider data management and claims processes, while nurturing a high-performance team environment

Drive cross-functional oversight of provider load and ensuring accurate and consistent application of business requirements and for provider data management and provider matching logic

Perform any other job duties as requested

Education and Experience:

• Bachelor's degree in business administration, healthcare administration, or a related field or equivalent years of relevant work experience is required
• Minimum of three (3) years of progressive experience in provider record data, claims data management or a related field, including claims outcome analysis, is required
• Facets experience is required
• Project management experience is required

Competencies, Knowledge and Skills:

• Proficiency in Microsoft Office suite
• Exceptional project management acumen, and a proven track record of successfully implementing new managed care products
• Ability to manage various complex projects and processes to completion

Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets

• Outstanding communication skills, both written and verbal
• Strong relationship management and collaboration skills
• Effective listening and critical thinking skills
• Strong analytical and problem-solving abilities

Certification:

Project Management Professional (PMP) certification preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time

Occasional travel may be required based on business needs