The role of theClaims Automation Manager is to plan, lead and execute Global AP Health Strategy related to automation of claims and pre-approval decisions, according to strict deadlines, priorities and within budget. The Automation& Claims Engine Manager is responsible for defining automation objectives, automated cost containment measures and KPIs for the initiatives under the scope of implementation and oversee delivery throughout its life cycle. He/she will lead the team of professionals that oversee implementing Controls, Rules and Edits inside and outside core operational platforms used for adjudication of claims across AP Health Entities. She/he will also be responsible for monitoring and controlling the performance of operational implementation across Health OEs and apply the necessary governance to ensure strategic alignment and value-oriented prioritization.
What you do:
Responsibilities will include, but are not limited to, the following:
- Clearly understands Global Health Strategy, defines tactical execution plan and ensures necessary stakeholder and functional alignment
- Clearly understand Global Operational needs and challenges, proposes viable and cost-benefit perspective solutions for the business in relation to claims automation and cost containment strategies
- Manages transversal team of claims automation experts
- Leads implementation transparently and productively, applying best practices
- Contribute to progress reports for internal and external audiences. Collates information for presentation at relevant committees as required
- Plans resource requirements within the budget allocated
- Effectively communicates with various stakeholders explaining the proposed solutions
- May require visiting and work closely with AP Health OEs to carry out work requirements.
- Responsible for developing, managing, and maintaining the Claims Adjudication Engines
- Ensures clinical coding compliance, coding education, and training of all operations audit units and staff.
- Ensures the Claims Edit Engines and Medical Controls knowledge base are properly and continuously updated based on International Medical References and requirements from the Payers
- Responsible for reviewing and customization of the rule’s engine according to the local market practices.
- Responsible for maintaining all types of Edits, Medical, Dental, Pharmacy and inpatient edits through collaborating with a team of experts to develop, deploy and implement all types of edits
- Responsible for monitoring the output of the system, analysis of changes and deviations, propose corrective measures
- Provides training as needed to all Ops teams to ensure their clear understanding of the system controls.
- Responsible of having an open line of communication with all Operations teams to share and communicate clearly.
- Gets feedback from Case Management and Fraud& Abuse Units to update the system output.
- Edits knowledge base and engines to increase the system intelligence and the quality of claims adjudication.
- Act as the lead expert and trainer across operations for all internal and external queries regarding edits and controls.
- Facilitate the involvement of staff and provide expert advice and guidance
- Responsible for the audit log of any system changes
- Assist in the development of the operations’ audit work plan and future audit activities as well as conduct and qualify clinical audit projects
- Assists in exploring data analysis and interpretation of findings
To be successful in this position you will need to have the following skills/ experience:
- In-depth understanding of health insurance operations and market trends.
- In depth knowledge and understanding of different coding standards e.g. ICD9, ICD10, CPT, HCPCs, Dental codes, ATC etc., and correlation between different types of codes e.g. ICD to CPT correlation
- Well-informed about the process of detecting Medical claims fraud and abuse practices (Contra-Indication, unbundling, double billing, …).
- Fair knowledge of regulations, practices, and trends in the industry.
- Experience in auditing operations process.
- Ability to coach and train operations staff.
- Able to demonstrate strong initiative with ability to work independently and maintain focus under pressure.
- Excellent Analytical Thinking and Problem-Solving skills.
- Demonstrable time management skills.
- Ability to deal professionally with external parties.
- Excellent interpersonnel skills
- High level of discretion in handling confidential information.
- Team player, who is comfortable working in a matrix environment with broad accountabilities.
- Fluency in MS Office applications
Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.
We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.
69386 | Project Management | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
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