Job description

ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources

POSITION SUMMARY

The Claims Manager is responsible managing and providing support the operations of a claims examiners and team leads. Establish work queues and oversees the quality and timeliness of claims examiner production levels, reporting any deficiencies to management. Provides guidance and works with leadership to establish policies on medical insurance claims in all lines of business. Knowledgeable in Medicaid and Medicare claims processing rules and regulations. Keeps abreast of any changes to legislation and regulations which pertain to insurance claims. Familiar with a variety of the auditing concepts, practices, and procedures and software solutions. Performs a variety of tasks. Relies on experience and judgment to plan and accomplish goals.

POSITION RESPONSIBILITIES

Control distribution of claims to examiners to meet processing / production goals. Ensure timely and accurate claim processing; assist with claim processing, as necessary.

Prepare management reports relative to production and quality; provide feedback to staff.

Review quality statistics / trends; coordinate efforts with the Quality Assurance Department to implement necessary steps for improvement.

Monitor written and telephone inquiries to ensure responses are sent accurately and timely.

Monitor correspondence activity and daily forecasting methodologies to meet departmental and client specific goals and objectives.

Monitor production of agents with regards to daily written correspondence activity, quality of service, and consistency of information.

Provide statistical analysis of the staff’s activity as well as provide executive level and quality assurance reports.

Support the department with strategic goals, implementation of new business and state/client audit reviews.

Resolve administrative problems and questions with members, providers, auditors and other internal/external departments for resolution of workflow issues.

Resolve administrative complaints and appeals to meet regulatory timeframes. Prioritize and meet all regulatory and client reporting

Review adjustments and correspondence to ensure accuracy and provide feedback to the staff Reduce State or Federal complaints through rapid response elevation process

Develop elevation process to insure rapid response to providers on highly sensitive inquiries

Keep management informed of issues adversely impacting service levels; suggest and / or implement corrective action.

Perform workflow analysis to improve processes; identify trends and reasons on incoming telephone and written inquiry volume; recommend and / or implement the necessary steps for improvement.

Review root cause of provider inquiries.

Collaborate with internal departments to implement change.

Participate in special projects as required.

QUALIFICATIONS:

• High School diploma/GED required; Associates or Bachelor’s degree preferred.
• Minimum three (3) year experience claims processing UB92 and HCFA 1500 claims required
• Leadership/management experience preferred
• Prior Supervisory experience preferred.
• Training experience, platform / presentation skills, project management and program design preferred; ability to effectively respond to queries (verbal and written) from clients, regulatory agents, management, and staff required

EEO STATEMENT In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

Job Type: Full-time

Pay: From $1.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Miami, FL 33166: Reliably commute or planning to relocate before starting work (Required)

Education:

• High school or equivalent (Preferred)

Experience:

• Management: 1 year (Preferred)
• Claims: 1 year (Preferred)

Work Location: Hybrid remote in Miami, FL 33166

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