Healthcare Claims Manager

4 hours ago

Quezon City, National Capital Region, Philippines Tenet Global Business Center, Inc. Full time $150,000 - $200,000 per year

SUMMARY

The Claims Manager oversees the claims process, ensuring timely, accurate, and compliant review of claims.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Ensures compliance with state and federal laws and regulations for Managed Care and other third party payors
  • Maintains a thorough understanding of Managed Care concepts including HMO, PPO, POS, EPO and capitation.
  • Develops strategies and mechanisms to ensure proper and timely follow-up of claim denials and accurate dispute code information in the Dispute Claims Management system (DCM); ensures a timely appeals process on denied claims for less than expected reimbursement.
  • Manages the aging of disputed A/R to ensure timely follow up and decision-making.
  • Provides on-going guidance and feedback to staff about denial reasons, appeals and their outcomes, and managed care contractual requirements. Participates in Payor meetings.
  • Ensures employee productivity and quality meets standards
  • Coordinates dispute issues with CRC and Facility RCM/Case Management as needed
  • Coordinates dispute issues with LVIT for escalation and resolution

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