Claims Program Manager- Payment Integrity

Company: SCAN Health Plan
Location: Long Beach
Posted on: November 1, 2024

Job Description:

Claims Program Manager - Payment IntegrityFull-TimeRemoteAbout SCANSCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.The jobThe Claims Program Manager (aka Claims Payment Integrity Program Manager) is an independent decision maker responsible for identifying and transforming processes/procedures in the Claims department specific to payment integrity. Requires interface with claims teams, payment integrity vendor(s), SIU, finance, and other applicable SCAN teams. Critical thinker who provides expertise bridging process and technology focusing on evolving functions, growing capacity, diversifying processes, and transforming the payment integrity aspect of claims, including increasing SCAN's recovered dollars. Responsible for coordinating efforts with team leaders, project managers, and departments outside of claims to effectuate best outcomes.You will

• Identify areas of technology support for manual functions through understanding of internal technology options and technology available in the market.
• Analyze efficacy of documentation for the payment integrity program and transform documentation style to reflect adult learning aspects.
• Develop and socialize program strategies, changes, and future state within the team, with leadership, and with vendors.
• Collaborate with SUI to identify and investigate FWA, including representing claims in CMS investigations.
• Collaborate with leadership regarding annual strategy including roll out of new programs and processes.
• Manage vendors and report to leadership on all aspects of the payment integrity program including multiple continuous and/or multi-year programs by planning project timelines and milestones, tracking progress, and monitoring/communicating project status.
• Make decisions regarding best practices, efficiencies, and implementation of decisions.
• Follow policies and procedures in order to maintain efficient and compliant operations.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.
• Identify through analysis and judgment, providers with billing practices inconsistent with standards and make a determination regarding reporting provider to SIU, communicate bad actions to internal teams as appropriate.
• Contribute to overall department success by participating in department initiatives, effective communication, and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers.
• Contribute to team effort by accomplishing related results as needed.Your qualifications
  • Preferred, but not required: Bachelor's or Master's degree in business administration, Health Care Management, Education or related field of study.
  • A comparable combination of education/experience and/or training will be considered equivalent to the education listed above.
  • 5-7+ years in a communication role, experience with payment integrity, recoveries, TPL, OIC or other payment related operations, presentation experience including senior leaders, and health and welfare benefit experience.
  • Health Insurance Benefits Management background in Medicare and Medicaid lines of business preferred.
  • Familiar with Medicare and Medicaid resources and is proficient in producing research results via such resources.
  • Knowledge of Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS) jurisdictions.
  • Knowledge of HIPAA regulations and privacy laws.
  • Communicate effectively and professionally with internal employees and external vendors (domestic and international).
  • Develop, analyze, and present program reports for senior leaders.
  • Develop process documentation reflecting an adult learning perspective.
  • Deliver presentations to leadership groups, vendors, and team in a cohesive, consistent manner.
  • Creative solutioning skills.
  • Critical thinking.
  • Decision making.
  • Demonstrated experience working in fast-paced or implementation environment.What's in it for you?
    • Base Salary range: $71,700.00 - $114,700.00
    • An annual employee bonus program
    • Robust Wellness Program
    • Generous paid-time-off (PTO)
    • Eleven paid holidays per year, plus 1 additional floating holiday
    • Excellent 401(k) Retirement Saving Plan with employer match.
    • Robust employee recognition program
    • Tuition reimbursement
    • A work-life balanceAn opportunity to become part of a team that makes a difference to our members and our community every day!We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
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Keywords: SCAN Health Plan, Mission Viejo , Claims Program Manager- Payment Integrity, Executive , Long Beach, California