Senior Manager Network & Claims Operations

Fulcrum Health, Inc. is a nonprofit, physical medicine benefit management organization that has delivered quality care through its network of over 4,800 licensed and credentialed physical medicine service providers for over 40 years.

Our product offerings include acupuncture, chiropractic, massage therapy, physical therapy, speech and occupation services, serving over 2 million health plan members.

Fulcrum continues to offer innovative and inspiring ways to leverage physical medicine that help lower health care costs, achieve better outcomes, and increase patient satisfaction.

POSITION PURPOSE :

The Senior Manager Network & Claims Operations is an accomplished change leader, demonstrating a flexible approach and resilience within changing environments, able to drive operational and cultural change.

The Manager is responsible for oversight of claims operations, provider dispute resolution, provider claims customer service, auditing, claim compliance, revenue recovery;

ensuring key performance metrics / SLAs for the claims processing and other integrated functions are met. The Manager will provide guidance to the leadership team regarding implementation of programs within other functional areas to improve quality and efficiency of network operations and claims processing.

This position oversees data integrity related to provider demographic and performance attestation in support of regulatory requirements and ongoing operational needs.

ACCOUNTABILITIES : Leadership

Leadership

• Manages escalated health plan client / carrier inquiries, operational department inquiries, and complex provider claim issues.
• Maintain communications and effective working relationships with clients, government agencies, vendors, internal business partners, and consultants as required for resolution of billing / claim issues and implementation needs.
• Develop a cross-functional team to document processes and procedures to address provider claim issues and inquiries to achieve high quality standards for client and provider services.
• Provide oversight to the Data Integrity Specialist role, which has accountability for integrity of the data for provider demographic attestations and assignments.

Daily Network and Claims Operations

• Responsible for administration of claims processing by providing business requirements and testing to meet Fulcrum and client business objectives.
• Monitor the claims vendor workflow to ensure timely, accurate submission and implementation of new client and provider contracting arrangements.
• Maintain knowledge and develop processes to support client and provider onboarding, regulatory claim requirements, payer fee schedules and line of business nuances.
• Lead service initiatives to improve provider and client experience, engaging cross functional internal and external stakeholders to :
• Document, research, and resolve issues identifying root causes and corrective actions.
• Empower staff by developing shared educational materials, resources, and procedures.
• Monitor and prioritize activities for provider communication, network and claims functional areas.
• In collaboration with Network Development, support the contracting process and timely onboarding of new providers.
• Research and help resolve provider contract and utilization management issues.
• Ensure providers have proper documentation to join and remain in the network. Maintain provider manual and policies.

Audits and Compliance

• Develop data entry audits to support staff self-auditing and corrections.
• Compile audit information and with peer leaders make recommendations to encourage staff performance and support resolutions.
• Implement claim operations solutions to meet regulatory requirements, test, and remediate gaps in new and existing production processes.

Oversees policy, procedure development and implementation for responsible areas :

• Leads development and maintenance of reimbursement policies, billing procedures incorporating industry standards and regulation when applicable.
• Assures claims business requirements are accurate by consulting with stakeholders and conducting system testing,
• Monitors billing submission and financial impacts of edits.

Vendor Performance

• Monitors vendor(s) performance to identify any process or quality gaps in alignment with best practices and contractual obligations.
• Provide input into the prioritization of projects within the company and represent Claims and Network Ops on cross-functional project work teams, identifying potential process improvements.

REQUIRED QUALIFICATIONS :

Minimum qualifications needed for this position)

Education :

Bachelor’s degree or equivalent experience with a combination of 5+ years of network operations, claims administration, claims payment, or payment accuracy in a managed care environment

Experience :

• 5 years of experience in healthcare network operations, claims management, claims processing, configuration, regulatory guidelines (CMS, DHS), and / or a strong knowledge of professional claims processing procedures internally or in a TPA environment
• 3 years in a leadership position, preferably in health insurance or TPA environment with customer service responsibilities

Skills and Abilities :

• Familiarity with medical bill forms, ICD-10CM coding, CPT coding, bill forms, and other medical coding schemes (certificate desired).
• Thorough understanding of network and claims operations and processes, to include provider contracting, network reporting, payment of claims, interpretation of contracts, communication of benefits, etc.
• Ability to manage network and claims operations vendors in a matrixed work environment.
• Exceptional team player with the confidence and integrity to earn client and internal team confidence and trust quickly.
• Proven attention to detail, follow-through, and problem-solving skills.
• Advanced level experience in Microsoft Word, Excel, Visio, and PowerPoint.
3 days ago