Hennepin Health is seeking a Claims Operation Manager to join their team. This person will lead their team in documenting claim-related benefit configuration requirements that will be supplied to the claims delegated vendor (FACETS claim adjudication system) to be configured. This position will also be responsible for the day-to-day claims-related backend audit activities required to ensure the claim delegated vendor is adjudicating claims according to the Provider and MN Medicaid contracts. The manager of this team will supervise two lead senior business configuration requirement analysts and three business analysts that document both the benefit and provider contract business requirements, complete the necessary business acceptance testing, and complete the monthly, and quarterly claims-related audits including error correction and reconciliation.
This role will work closely with Claims Delegated management, Hennepin Health Government programs, Medical Administration, Network Management, and Provider Data operations department to operationalize the benefit requirements change control process within the systems and business processes. Strong operational management abilities, technical competency, proactive problem solving, and organized resource manager skills are needed to be successful in this role.
Current Hennepin County employees who refer a candidate hired into an open competitive position may be eligible for a $500 referral bonus. For more information visit employee referral program.Location and hours:
This position is hybrid and will be performed both remotely and on-site at 525 Portland Avenue South, Minneapolis, MN as job duties require. Work hours will be Monday through Friday, between the hours of 8 a.m. - 4:30 p.m. While this position is designated as hybrid, based on current requirements hires must reside in or relocate to Minnesota or Wisconsin.
New employees who are hired into remote or hybrid positions between January 2, 2022 to December 31, 2024, will receive $500 toward the cost of establishing consistent internet connectivity, payable upon completion of 6 months of employment. About the position type:This is a full-time, benefit-earning position. This position is internally classified as an Administrative Manager, Senior. Click here to view the job classification specification.
Note: You must attach a resume as part of your application materials to be considered for this position.In this position, you will:
Manage the end-to-end business development of the benefit and provider contract configuration requirements process to ensure the health plan product benefits and provider contracts are implemented timely and accurately in collaboration with the claims delegated vendor.
Manage the monthly and quarterly claims audit process including error correction, reconciliation, claims recovery; manage the annual claims accuracy audit in coordination with Hennepin County Internal Audit and the third party audit firm.
Develop and document new departmental business policy and procedures and update existing policy and procedures on an annual basis; ensure adherence to the policy procedures.
Develop collaborative relationships across Hennepin Health (Medical Administration, Finance, Provider Contracting, and Provider Data operations) to proactively address existing issues or new changes that impact the service delivery to our members and providers.
Ensure quality assurance processes are followed and all approvals are obtained before configuration changes are moved into production.
Manage, monitor, and troubleshoot all details of claim processing audit activities including root cause analysis, error correction and reconciliation processes, claims recovery projects.
Supervise and manage direct reports including annual performance reviews, probationary reviews, individual development plans, conduct regularly scheduled coaching sessions.
Manage work assignments with staff until completion; support and adhere to issue management and change management processes.
Need to have:
One of the following:
Bachelor's degree or higher in business administration, computer science or an approved field related to the business/position and five years or more of benefit configuration experience in a health plan payer environment and/or strong operational management in a health plan provider system.
Nine years or more of benefit configuration experience in a health plan payer environment and/or strong operational management in a health plan provider system.
Nice to have:
Experience in benefit configuration positions such as benefit configuration design, development, or benefit configuration management in a health plan payer environment.
Project management or business analysis certification.
In claims configuration.
Supervising staff or being a team lead.
Identifying patterns within quantitative data, drawing conclusions, and recommending solutions and approaches, skilled with end-to-end issue resolution.
Claims clinical coding (CES Optum).
Provider pricing, product, and benefits analysis.
Health plan claims processing configuration system (e.g. Facets).
Interact effectively with other areas of the organization regarding Claims Transactions.
Manage multiple assignments while maintaining quality standards and meeting assigned deadlines.
Use Microsoft Excel and Word at an intermediate or greater level of proficiency.
Provide excellent oral and written communication, interpersonal skills, and organizational abilities.