Healthcare Claims Project Manager

Job Description

Job Description

Job Title : Healthcare Claims Project Manager

Job Summary : We are seeking a highly skilled and experienced Healthcare Claims Project Manager to join our consulting team.

This pivotal and dynamic role reports directly to the Program Director in this respective business unit of the company and offers significant growth potential.

The ideal candidate will possess extensive knowledge of Medicare claims processing and various healthcare claims payment disciplines, including payment audits, appeals, CMS rules and regulations, benefit configuration, COB, enrollment, and provider networks.

Additionally, the candidate should understand the different files used in enrollment and claims processing (834, 835, 837, etc.

and have a general understanding of file transfer processes.

Key Responsibilities :

• Oversee and manage healthcare projects related to claims processing and payment.
• Analyze and interpret Statements of Work (SOWs) and Requests for Proposals (RFPs) to identify opportunities, research solutions, and develop cohesive strategies for implementation.
• Lead projects or manage subcontracted portions by thoroughly investigating opportunities and formulating strategies to ensure successful execution and compliance with client requirements.
• Manipulate and analyze medical claims data in Excel, utilizing pivot tables and other advanced Excel techniques to identify trends and insights.
• Manage and execute OR Assist in project budgets, ensuring resources are utilized effectively within the established budget.

While having an overall understanding of budget creation.

• Develop and implement strategies to improve claims processing efficiency and accuracy.
• Collaborate with clients to understand their needs and provide tailored solutions.
• Analyze and interpret claims data to identify trends, issues, gaps or key areas of focus for the project at hand.
• Ensure compliance with all relevant regulations and standards.
• Coordinate with IT teams to manage file transfers and ensure data integrity.
• Provide training and support to clients and team members on claims processing and payment systems.
• Prepare detailed reports and presentations for clients and stakeholders.
• Monitor project progress and adjust plans as necessary to meet deadlines and objectives.

Qualifications :

• Minimum of 5+ of experience in healthcare claims processing and payment.
• 3+ years of exposure to leading and managing programs that range from 3+ full time resources and at / above $4M in total budget.
• Experience working with multiple claim payment systems that support activities in the end-to-end claims processing flow.
• Strong understanding of various claims processing files and file transfer processes.
• Excellent project management skills with a proven track record of managing complex healthcare projects.
• Strong analytical and independent problem-solving abilities in a fully remote environment.
• Excellent communication and interpersonal skills working in a cross-collaborative environment.
• Proficiency in relevant software and tools (e.g., Excel, MS Planner, MS project, EncoderPro, Codify, SharePoint, Salesforce).
• Ability to work independently and as part of a team, which can extend beyond J29

Preferred Skills :

• Experience in a healthcare consulting environment serving government programs.
• Knowledge of healthcare regulations and standards.
• Familiarity with claims related to Medicaid, TRICARE, and group health plans is a plus.
• Management and leadership skills ranging from a team of direct or indirect reports that are supporting claims or record review
• Exposure to State or Federal contracts with direct engagement with government stakeholders
• Certification in project management (e.g., PMP, PRINCE2).

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