Department: 500620 Reimbursement Svcs
Facility: Hometown Health
Reno, NV
Schedule: Full Time - Eligible for Benefits
Shift: Day
Hours: 0800 to 1700
Job Details:
  • Position Purpose:

    Under the direction of the Manager of Claims, this position oversees all daily claims processing operations and functions.  This position is responsible to ensure timely and accurate processing of claims for HMO, PPO, TPA and Dental products for fully funded/self-funded commercial members and Senior Care Plus members.

    Nature and Scope:

    The incumbent is responsible for:

     

    • Ensuring claims are adjudicated according to health plan procedures, department procedures, State and Federal Regulations and Laws, member benefits and provider contractual agreements.
    • Human Resources issues including hiring, disciplinary action and termination under direction of the Manager of Claims.
    • Developing and implementing the Coordination of Benefits and Subrogation portions of claims adjudication for the health plan. 
    • Developing and implementing training programs for Claim Examiners in regards to coordination of benefits and subrogation as it pertains to claims processing.  This may include training for other Hometown Health Departments, provider offices and employer groups in regards to claims processing.
    • Determining health plan participation in coordination of benefits and subrogation programs through research of state/federal laws and regulations, Department of Insurance and legal counsel.
    • Assisting in developing and implementing collection/recovery efforts for subrogation.  
    • Ensure appropriate financial procedures are developed for proper coordination of benefits and that subrogation monies are deposited and credited to the appropriate fund/member. 
    • Recommending necessary changes in staffing to ensure accurate and timely claims processing.
    • Delegating work, establish appropriate timeframes and implement necessary procedures and protocols to ensure accurate and timely claims processing. 
    • Working with other Departments to ensure appropriate communication and procedures are established within the Health Plan. 
    • Being a representative of Renown and Hometown Health to vendors, providers, employer groups and members.
    • Ensure the current processing and support procedures are updated.  
    • Completing projects as assigned by the Claims Manager or other health plan management.  This will include following established project management procedures.
    • Participating in quality improvement and change management procedures and processes.

     

    This position does not provide patient care.  

    The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

    Minimum Qualifications:  Requirements - Required and/or Preferred

    Education:

    Must have working-level knowledge of the English language, including reading, writing and speaking English.

    Experience:

    Minimum two years of healthcare experience with a knowledge of claims required.  Previous supervisory experience preferred.  Preferred prior experience includes on-line claims adjudication, Coordination of Benefits diversions and Subrogation Recoveries.  Thorough knowledge and application of medical terminology, CPT, ICD9/10, HCPCS, ASA, ADA and DRG coding is highly preferred.  Knowledge of State and Federal rules and regulations is required. 

    License(s):

    None.

    Certification(s):

    None.

    Computer / Typing:

    Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.

     


  • EEO/M/F/Vet/Disabled


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