Head of Claims at Pivotage Consulting

Ref Id: MHT/1121/HOC
Career: Mid/Level Expert

Job Purpose

• This position is responsible for claims processing and administration. It also includes analysis of utilization and claims patterns to identify areas of improvement and process changes that will result in medical cost control.

Job Responsibilities

• Coordinating the management of all Claims processes from submission, initial review, sorting and tracking, pre-processing, adjudication, review, scheduling for payment and then reconciliation and sign off on paid claims.
• Ensuring accurate processing of all claims following proper enrollee verification, enrollees eligibility, PA confirmation, and according to contracted fee schedule with provider.
• Ensuring timely processing of claims and appeals on FIFO bases to ensure payment within 30 days of receipt of claims at any of our office.
• Ensuring proper filing and maintenance of claims documents and make sure the information is readily available.
• Conducting a review of processed claims for errors and ensure accuracy of processed claims and preparation of claim schedules for payment
• Responsible for the supervision of the staff in claims unit including training and team building.
• Providing regular reports on claims status, receipt, processed and payment.
• Monitoring and evaluation of utilization patterns by
• Analyzing  of preauthorization reports to identify regional and provider specific trends and propose process changes and policies for effective utilization management
• Analyzing of claims reports to identify regional and provider specific trends and propose process changes and policies for effective utilization management
• Providing regular reports on claims status, trends and utilization patterns.

Job Requirements

• Must have a Bachelor's degree in a relevant discipline.
• Must have a minimum of 5 years progressive career history
• Must have prior experience in similar role and team management skill is a must.
• Must have a good network of prospective members and ability to close sales.
• Must have strong understanding of customer and market dynamics and requirements.
• Must have the ability to take initiatives and accept challenges.
• Must have the ability to be upright in areas of personal character, commitment, organizational, communication and persuasive skills.
• Must have the ability to maintain accurate records of all claims activities and continuously adhere to all company policies, procedures and business ethics codes.

Salary
Competitive and negotiable.