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Manager of BH Medical Claims

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MetroPlus Health PlanRussell, IA
  • Job Description: Job Description About NYC Health Hospitals MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health Hospitals, the largest public health system in the United States, MetroPlus network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • Position Overview Under the general direction of the Claims Director/Senior Director, the Behavioral Health Medical Claims Managers task is to ensure consistent oversight of Behavioral Health Claims and Medical Claims.
  • Oversee the performance and quality of claims outcomes to ensure adherence to all contractual and regulatory requirements Job Description Expected to be the subject matter expert on Behavioral Health and Medical claims processing rules and guidelines.
  • Serve as primary organizational contact for all behavioral health claims related issues.
  • Monitor and evaluate performance, and effectiveness of claims operations continuous, determine its effectiveness, in meeting and/or exceeding contractual and regulatory requirements.
  • Manage claims operational reports for visibility into vendor performance trends.
  • Track, measure, report, and evaluate vendor performance.
  • Stay apprised of changes to contracted services, and oversight activities are performed while ensuring the behavioral health vendor is aware of performance expectations and their own performance metrics.
  • As issues are identified, work with vendor to identify root cause and corrective action plans to avoid a reoccurrence of the issue.
  • Oversee the behavioral health and medical claims quality assurance process.
  • Identify risks and implement plan to monitor and address risk related tasks.
  • Develop and implement a behavioral health and medical claims testing and auditing process.
  • Perform ongoing monitoring of the claims process to ensure claims are processed accurately and are compliant with regulatory guidelines.
  • Document and report findings.
  • Conduct and/or participate in regular meetings, telephone calls and formal vendor communications and notifications.
  • Minimum Qualifications Three plus (3) years of vendor management, contracts, and relationship management experience.
  • Bachelors degree requiredExperience working in a managed care organization, medical /behavioral claims processing, and knowledge of regulatory requirements affecting medical/behavioral claim outcomes.
  • Industry knowledge: Understands behavioral health/medical claims processing guidelines, and have knowledge of local, state, and federal health care regulations.
  • Performs all duties inherent in a managerial role.
  • Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hires, promotes, and terminates staff, as appropriate.
  • Skilled at directing and motivating others.
  • The ideal candidate will be able to flex his/her style and direct, collaborate or empower others as the situation requires so that the plans goals are met.
  • This leadership position must establish and maintain productive relationships with multiple stakeholders, with internal and external stakeholders.
  • Excellent customer/client service aptitude.
  • Flexible and adaptable in handling and implementing change.
  • Must be a self-motivated individual who grasps concepts quickly, takes proactive ownership of task or processes and is a team player.
  • Ability to manage multiple projects/tasks in a dynamic environment with minimal direction, prioritize, and multitask independently.
  • Detail oriented with analytical proficiency, able to navigate ambiguous situations, investigative thinking.
  • Excellent written and verbal communication skills with the ability to effectively communicate and interact with all levels of personnel within the organization, including presenting information and responding to questions from groups of managers, clients, customers, and the public.
  • Extensive knowledge across different functional areas.
  • Proficiency in Excel require.
  • Other duties, as assigned.
  • Professional CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical skillsWritten/Oral Communication

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