Manager, Claims Special Projects

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

Remote position - must reside in California.

What You Will Be Doing :

Under limited supervision, supports current and future organization strategies and objectives impacting the Claims Department and is responsible for managing projects that require collaboration between the various areas of the organization, as well as external entities.

Work is highly varied and complex and requires a moderate degree of discretion and independent judgment.

Our Vision :

Continuously improve the health of our community.

Our Mission :

We provide healthcare value and advance wellness through community partnerships.

Essential Functions

• Supports the research and development of innovative or pilot programs, services, products, and ventures.
• Provides strategic and tactical support to the Claims Director to coordinate and help drive the development of strategic plans.
• Serves as the key content expert for projects and ensures leadership engagement.
• Supports development, implementation, and maintenance of best practice methodology, including but not limited to technology, policies, procedures, processes, tools, and standards;

ensures their dissemination and understanding amongst the claims department divisions and other impacted stakeholders.

• Ensures operational preparedness for and compliance with regulatory changes and state audits and supports these activities through interdepartmental collaboration.
• Socializes understanding of new initiatives and strategies among the claims department and other key stakeholders.
• Develops, implements, and maintains the appropriate and required data, records, reports, and other documentation.

What You Have :

Education and Experience

Required

• Bachelor's degree in business or healthcare administration, or similar disciplines; and
• At least five years progressively responsible healthcare claims experience, which includes all aspects of claims administration; and
• At least five years in using QNXT or similar systems; including all QNXT or similar system modules related to the claims experience.
• At least three years' experience in using other claims-related applications including Claims Edit Systems (CES) and other integrated pricing systems.
• At least three years' experience in project management, operations, product development, and healthcare delivery system innovation.
• At least three years' experience in Managed Medi-Cal / Medicaid and Medicare programs; or
• The equivalent of experience and education combined.

Licenses, Certifications

Required

Completion of a Coding Certification Program (credentialed through AAPC preferred)

What You Bring :

Knowledge, Skills, Abilities and Competencies

• Strong knowledge of health care core administrative functions, their strategic impact and integration with other health care functions.
• Comprehensive knowledge of Medi-Cal and Medicare programs and regulations.
• Advanced assessment and analytical skills, including the ability to synthesize, distill concepts, draw conclusions, and identify implications.
• In-depth knowledge of the flow of data and information through a health plan.
• Basic knowledge of database concepts and terminology, including interrelationships between data fields.
• In-depth knowledge of provider and / or facility contract and payment structures, and reimbursement practices.
• In-depth knowledge of procedure coding, medical terminology, and their application to claims operations.
• In-depth knowledge of general medical benefits and exclusions.
• Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of the organization.
• Strong oral and written communication skills, including the ability to communicate professionally and persuasively to diverse individuals and groups inside and outside the organization.
• Strong collaboration skills, including but not limited to the ability to create and foster a collaborative work environment, and organize people and resources to solve problems and identify opportunities.
• In-depth knowledge of change management theory, with ability to anticipate and implement effectively.
• Demonstrated ability to articulate and support the organization's vision, mission, values, and strategy, and integrate into management practices.
• Advanced skills in Word, Excel, PowerPoint, Visio, and project management software.
• Ability to speak and be understood in English.
• Ability to treat confidential information with appropriate discretion.

Preferred competencies

• Produces work that is accurate and complete
• Drives Results
• Ensures Accountability
• Manages complex and ambiguous projects
• Demonstrates savvy organizational skills
• Demonstrates Persuasion skills
• Demonstrates strategic thinking

What You Will Get : HPSJ Perks :

HPSJ Perks :

• Competitive salary
• Robust and affordable health / dental / vision with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee's birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven - our members and community are at the core of everything we do.
• A shorter commute - if you're commuting from the Central Valley to the Bay Area.
• Visibility and variety - you have a chance to work with people at all levels of the organization, and work on diverse projects.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve.

Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws.

It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.

Important Notice : This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.