Virginia Premier Health Plan Manager, Claims Research & Resolution in Glen Allen, Virginia

About Us

Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.

By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.

At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.

If this sounds like you, read on!

Overview

The Claims Research and Resolution Manager will have direct oversight of the Research and Resolution team, assisting the Research and Resolution Director in the daily and/or monthly operational and administrative duties, to ensure the efficient and effective performance of the staff. This position is intended to be a supportive role to the staff; therefore, the Manager serves as a liaison for the staff. This position will be responsible for understanding all Research and Resolution department tasks in addition to handling other administrative duties. The Claims Research and Resolution Manager will work collaboratively with the other Research and Resolution Manager and the Provider Resolutions Manager in developing policy, procedures, and creating Sop’s for the Research and Resolution department. The Claims Research and Resolution Manager will also be responsible for training new employees as well as training the team for any new or updated claims processing platforms. The Claims Research and Resolution Manager will act as a liaison for internal team and external providers to ensure claims issues are tracked, identified, and resolved. The Claims Research and Resolution Manager is responsible for Reconsiderations and claims escalations for all lines of business.

Responsibilities

  • Evaluate, distribute, and monitor work to ensure all functions of the Claims Research and Resolution Team are being completed according to department standards including, but not limited to Macess Reconsiderations, DMAS escalation, CMS escalations, Provider escalations and ChangeGear tickets.

  • Maintain and Report daily Research and Resolution inventory

  • Monitor team production

  • Assists with Provider Escalations

  • Assists staff with questions and issues

  • Handle more complex and Provider issues

  • Conduct detailed research on claims issues

  • Assist in the creation of policies and procedures

  • Research and resolve claims issues that have been escalated by providers through Claims Reconsiderations and Claims Inquiries that are brought forth by Claims Customer Service and Network Development

  • Coordinate claims resolutions with all appropriate departments in order to resolve issues

  • Perform or arrange for Research and Resolution Team training and development initiatives

  • Research and respond to requests from other departments

  • Complete Special projects and more complex claims issues

  • Coordinate claims resolutions with all appropriate departments in order to resolve issues

  • Process, adjust, and key claims accurately and timely following established guidelines for accuracy, quality, and productivity

  • Identify, track and trend claims payment errors in order to determine root causes and actions needed to correct problems

  • Identify trends from provider complaints regarding code edits and business decisions that impact claims payments

  • Attend Provider JOC Meetings

  • Attend Provider Education Meetings

  • Perform other miscellaneous duties/activities as assigned

  • The ability to work overtime as needed

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • High School diploma required

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Strong communication skills (both verbal and written)

  • Exposure to health care call center environment

  • Ability to conduct research independently

  • Experience with IDX and QNXT Claim processing systems

  • Ability to ensure departmental goals and deadlines are met

  • Ability to work independently as well as in a team environment

  • Strong organizational skills

  • Strong interpersonal skills

  • Knowledge of Home health, Skilled Nursing facility, and Hospice claims

  • Knowledge of Medicaid and Medicare claims processing

  • Provider Reconsideration knowledge

  • Ability to lead or provide instructions to others

  • Ability to train and develop others

WORK BACKGROUND/EXPERIENCE

  • Minimum 3 years claims processing experience, preferably with Medicaid and Medicare

  • IDX and QNXT Claims processing system experience

  • Minimum of 2 years supervisory or leadership experience

PHYSICAL REQUIREMENTS

  • Physicalhealth sufficient to meet the ergonomic standards and demands of the position

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

Our mission is to inspire healthy living within the communities we serve!

Job ID 2018-5403

As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.