Inland Empire Health Plan

The Manager, Claims Processing - Covered California is responsible for oversight and direction of claims and auditing activities of the Covered California (CCA) vendor and personnel.. Oversee of Covered California claims adjudication and quality by vendor.. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.. IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.. The Manager must have past Covered California or Commercial claims processing experience

claims processing

What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! The Manager, Claims Processing - Covered California is responsible for oversight and direction of claims and auditing activities of the Covered California (CCA) vendor and personnel. This position requires excellent communication, collaboration and leadership skills and the ability to provide detailed instructions to vendor and staff while monitoring inventory and compliance metrics within the department to ensure that our provider and member needs are met in a timely manner. Major Functions (Duties and Responsibilities) 1. Interface with vendor to review daily productivity/quality/inventory due to compliance. 2. Coordinate business rules/EOC changes with vendor 3. Collaborate with providers and senior leadership to address escalated claims issues. 4. Work closely and attend meetings with the Senior Director and Director of Claims. 5. Participate in regulatory audits and corrective action plans. 6. Oversee reporting needs and request. 7. Promote process improvements methodologies and best practices that enhance claims service with vendor. 8. Monitor and report key performance metrics in jeopardy of compliance risk with vendor. 9. Oversee performance monitoring and claims inventory management for Covered California claims processed by vendor. 10. Oversee of Covered California claims adjudication and quality by vendor. 11. Partner and collaborate with various areas and vendor for resolution on claim issues. 12. Engage in regulatory audits and CAP remediation. 13. Hire, train, and manage support staff, while monitoring and evaluating outcomes. 14. Conduct performance reviews of each Team Member within IEHP guidelines. 15. Any other duties as required to ensure the Health Plan operations are successful. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Perks IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more. CalPERS retirement 457(b) option with a contribution match Generous paid time off- vacation, holidays, sick State of the art fitness center on-site Medical Insurance with Dental and Vision Paid life insurance for employees with additional options Short-term, and long-term disability options Pet care insurance Flexible Spending Account – Health Care/Childcare Wellness programs that promote a healthy work-life balance Career advancement opportunities and professional development Competitive salary with annual merit increase Team bonus opportunities Education & Experience Five (5) years of claims processing experience, at least (3) three of which was in a management capacity Three (3) years of experience in an HMO or managed care environment. Experienced in benefit and interpretation, regulatory payment appeals, and claim adjudication The Manager must have past Covered California or Commercial claims processing experience Bachelor’s degree from an accredited institution required, degree preferably in Business Administration, Accounting or Healthcare from an accredited institution required Key Qualifications Excellent communication, collaboration, and leadership skills. Start your journey towards a thriving future with IEHP and apply TODAY!

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