Manager, Claims & COB
Requisition #: 191125
Location: Johns Hopkins Health Care,
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Oct. 14, 2019
Johns Hopkins Health System employs more than 20,000 people annually. When joining the Johns Hopkins Health System, you became part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. Great careers continually advance here.
Responsible for planning, managing and organizing the functions of the claims department. Coordination of the activities of workers engaged in all aspects of examining and adjudication of claims. Sets Goals, Motivates and Aligns Organization: Inspires staff and generates commitment to program and project goals. Builds Relationships and Fosters Teamwork: Demonstrates the ability to build relationships across the organization and teamwork within their organization. Manages Service Excellence: Ensures employees deliver excellent customer service. Employees treat customers (guests, members, providers, and all other employees) with courtesy, respect, and caring behaviors.
- Planning, managing and organizing the functions of the USFHP claims department, and the coordination of the activities of workers engaged in all aspects of examining and adjudication of claims to ensure a high level of member and provider satisfaction with the health plan. The US Family Health Plan is a highly visible, high-value segment of the JHHC book of business. It is subject to a level of scrutiny above the norm from elected officials, high-ranking military personnel, and JHHS executives due to the nature of the contract with the D.O.D. and its’ significant contributions to the organization’s fiscal viability. Accordingly, a level of care, diligence, professionalism, and execution beyond the norm is expected and required from the incumbent.
- Planning, managing, and organizing the functions of the COB unit for all JHHC lines of business. These functions are: coordination of benefits, subrogation, workers compensation, overpayment recovery, and claims adjustments. Coordination of the activities of internal staff and a variety of outside contractors engaged in all aspects of these various functions. Making certain that COB activities maximize savings for JHHC without impeding upon or negatively impacting claims and service operations or member and provider satisfaction.
Work requires a professional level of business administration and/or management generally obtained in the first two years of college or equivalent years of experience specific to claims adjudication and customer service. Bachelor’s degree in business administration/management or related discipline preferred.
Work requires a comprehensive and expert understanding of claims processing to include medical, dental, institutional, subrogation, reinsurance and short-term disability claims processing, benefits and data entry administration and mail room management service performance standards and criteria as acquired during three to five years of progressively more responsible claims management experience specific to these functions with at least 5
years of supervisory experience in a managed care environment. Familiarity and knowledge of Medicaid plans beneficial.
Requires a comprehensive and expert understanding of medical claims processing data entry administration and mail room management standards. Knowledge of military health plans, Medicaid plans, and employer sponsored health plans is required, along with an understanding of paperless work flow applications and the use of technology, i.e. EDI claim submissions, in claim processing. Familiarity with mail-room operations and how they tie in with claim processing is needed. Understanding of the basic operations of call centers, customer service, and other related “back office” functions in a health plan are necessary.
Requires an understanding of the concepts of data collection and data analysis to identify trends and patterns in claim processing to monitor operational performance. The ability to tie seemingly unrelated events together is critical. The ability to summarize and report on this data, along with the ability to present it to senior management in a concise and factual style that allows senior management to make operational and financial decisions is important.
Requires a comprehensive and expert understanding of third party liability, coordination of benefits, workers compensation, collections, auditing for overpayment recovery, Medicare secondary payer rules and regulations, and how those rules relate to claim processing. Knowledge and expertise in the application of NAIC guidelines in coordination of benefits is necessary. Knowledge of local statutes, Federal regulations, subrogation theory and COMAR is required so the daily operations of the COB and claims departments are conducted in compliance with those various requirements. Knowledge of all JHHC lines of business is required.
Requires the ability to manage an annual departmental budget of $1.5 million and accomplish objectives within that budget.
Work requires strong analytical ability to resolve complex problems, gather and interpret data from different sources and to complete assigned tasks and projects.
Work requires the ability to handle sensitive and confidential information, communicate and exchange information with all levels of staff and external business-related agencies and members.
Work requires incumbent to be self-motivated and able to work independently to assess situations and respond appropriately, make independent decisions and the ability to accept change.
Requires ability to effectively motivate and manage staff of 20-25 employees, supervisors, and team leaders to meet departmental and corporate objectives. Ability to effectively delegate tasks to the appropriate level of the organization.
Requires excellent communication, writing and interpersonal skills to effectively interface with all levels of staff, particularly with executive-level staff with oversight of USFHP program.
Requires the ability to think freely and challenge the conventional wisdom on all aspects of the day to day functions of the Operations Department, and to gather, analyze, and report on data to draw conclusions and make recommendations on changes to policies and processes in the Operations Department.
Requires the ability to manage a call center handling inbound and outbound calls for the Coordination of benefits unit.
D. Required Licensure, Certification, Etc.:
E. Work Experience:
5 to 7 years of experience in a managed-care health plan environment, with experience in COB operations or claim processing functions. Requires at least 5 years of progressively responsible management experience. Experience in basic data collection, compilation and reporting is necessary. Experience with electronic work-flow applications, web-based databases, and general understanding of the application of technology in a health insurance context is preferred. Understanding and use of basic reporting tools such as MS Excel and Access, and associated graphing, charting, and report presentation is required.
Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.