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Healthfirst

Manager, Claims Configuration

New York, NY

The Manager, Claims Configuration is responsible for overseeing the accurate, compliant, efficient and timely configuration of claims business rules. This encompasses provider reimbursement, implementation of provider contracts (standard & nonstandard), maintenance of published rates and functionality including business validation of claims core application changes for all Healthfirst lines of business The Manager is expected to provide leadership and effective coordination across departments to ensure the successful execution of Claims Configuration business rules and will also support departmental and enterprise level projects of strategic importance and major complexity.

Duties & Responsibilities:

  • Provide leadership to and accountable for supervising the day to day performance of an assigned Claims Configuration team.
  • Drive team performance through audits and coaching. Direct team members to resolve business problems through active collaboration.
  • Assure the onboarding and training of new and existing staff to support product growth and service enhancement.
  • Establish Claims Configuration process direction, identify interdependencies, oversee the communication of configuration requirements, track progress, make decisions, and resolve conflicts.
  • Ensure consistency in running and reporting configuration activities to maintain compliance with both State and Federal CMS and Medicare Advantage regulations
  • Ensures all NY state and federal compliance, audit and regulatory requirements are met
  • Research, identify, and recommend industry best practices to support high quality, cost effective implementations and on-going program changes.
  • Set standards and guidelines on how to unambiguously define and describe business and system requirements.
  • Ensure business and quality objectives are obtained by facilitating process improvement through open communication and fact-based decision making.
  • Review processes, make recommendations and implement new policies and procedures regarding claims configuration, claims analysis, standardized reporting, etc.
  • Ensure quality control measures are in place and being adhered to with utilization of claims processing engine and claims configuration through business validation and regression testing.
  • Conduct ongoing root cause analysis and summarize findings with recommendations to senior management
  • Additional duties as assigned.

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Minimum Qualifications:

  • Bachelor's Degree from an accredited institution or equivalent work experience
  • Experience supervising employees, developing performance standards, coaching, training, conducting performance reviews, and making personnel decisions.
  • Demonstrated organizational and planning skills in supervising multiple projects, deadlines, and priorities in a fast-paced work environment.
  • Experience working on highly cross-functional project teams to produce meaningful results. Must be able to work effectively with both business and technical stakeholders at all levels including Executive Management.
  • Knowledge of medical claims adjudication procedures, including the application of medical policy (authorizations) guidelines, contract pricing and member benefits to claims processed.
  • MS Excel skills: ability to create and use Excel reports to manage information by using features such as search/find, sort/filter, formatting, inserting columns/rows/field, creating additional worksheets/tabs, formulas, and creating pivot tables.

Preferred Qualifications:

  • Strong attention to detail, with ability to also focus on the bigger picture.
  • Comprehensive knowledge of managed care industry and product administration/implementation.
  • Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
  • Hands-on experience with rules based/table driven claims and eligibility administration systems.
  • Experience in managing projects across multiple departments or leading high level cross functional teams.
  • Demonstrated ability to exercise judgment and discretion of sensitive and/or confidential matters.

Compliance & Regulatory Responsibilities: See above

License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range:

  • Greater New York City Area (NY, NJ, CT residents): $98,400 - $142,205
  • All Other Locations (within approved locations): $84,400 - $125,545

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.

Client-provided location(s): New York, NY, USA; Florida, USA
Job ID: healthfirst-R016191
Employment Type: Other

Perks and Benefits

  • Health and Wellness

    • Health Insurance
    • Health Reimbursement Account
    • Dental Insurance
    • Vision Insurance
    • Life Insurance
    • Short-Term Disability
    • Long-Term Disability
    • FSA
    • HSA
    • Fitness Subsidies
    • Mental Health Benefits
    • Pet Insurance
  • Parental Benefits

    • Birth Parent or Maternity Leave
    • Family Support Resources
  • Work Flexibility

    • Remote Work Opportunities
    • Hybrid Work Opportunities
  • Office Life and Perks

    • Commuter Benefits Program
    • Casual Dress
    • Happy Hours
    • Company Outings
    • Holiday Events
  • Vacation and Time Off

    • Paid Vacation
    • Paid Holidays
    • Personal/Sick Days
    • Volunteer Time Off
  • Financial and Retirement

    • 401(K) With Company Matching
    • Performance Bonus
  • Professional Development

    • Internship Program
    • Tuition Reimbursement
    • Promote From Within
    • Access to Online Courses
    • Lunch and Learns
    • Associate or Rotational Training Program
    • Learning and Development Stipend
  • Diversity and Inclusion

    • Employee Resource Groups (ERG)
    • Woman founded/led
    • Diversity, Equity, and Inclusion Program

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