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Assistant Manager, Hospital Claims
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- Ensure timely and accurate facility claims processing in accordance with member benefit and eligibility parameters, Summary Plan Description (SPD) and Coordination of Benefits (COB) guidelines, regulatory and pre-authorization requirements, Claim Check/National Correct Coding Initiative (NCCI) rules, provider contract terms and timeframes, and Fund/departmental policies
- Monitor QNXT reports, and work queue distribution/completion in the Document Management System (DMS), QNXT Pend Workflow, and QNXT Call Tracking systems
- Work directly with the staff, Funds’ claim review vendors, and act as liaison with Care Management, Provider Relations, Eligibility, Clinical Compliance, Liens, QNXT Production Support, and IT, to resolve outstanding issues
- Manage staff in accordance with established departmental/Human Resources guidelines and provisions of the Collective Bargaining Agreement; ensure staff training and skill development to meet departmental needs/goals and Health Insurance Portability and Accountability Act (HIPAA)/Compliance standards
- Minimum four (4) years with hospital claims processing or health claims Quality Control Reviewer/Auditor required; to include a minimum of two (2) years supervisor experience required
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