Claims Department Manager
Report to: President

A progressive third-party administrator of union health and welfare benefits, is seeking an experienced Claims Department Manager with a proven track record in Managing a Claims Processing Department to join their dedicated team. This is a highly visible leadership position.

The Claims Department Manager manages day-to-day claims operations, including claims evaluation, adjudication, analysis, auditing, and customer service, in accordance with quality and production standards. Ensures that claims are processed in a timely manner in compliance with company policies and applicable regulations, concerning the processing of claims. Oversees 2 Assistant Managers in managing a staff of 12 Claims department employees for performance, HIPAA Compliance, following company policies and attendance requirements. Oversees preparation, analysis and distribution of various reports, as well as; Medical Review letters, Appeals and other Claims related information/documentation.

Requirements:

Bachelor’s Degree preferred and a least 10 years of experience Supervising claims processing, encompassing knowledge and understanding of group benefit plans, how they relate to claims processing; including plan benefits, eligibility, limitations, exclusions, etc.

Requires experience in on-line claims adjudication and a working knowledge of claims codes and descriptions, medical terminology, PPO provider guidelines, eligibility, limitations, exclusions, case management and medical review.

Must be familiar with medical terminology, R.V.S., C.P.T., I.C.D.A., Diagnosis Codes (ICD-10), and H.C.P.C.S. codes.

Ability to develop knowledge and understanding of company and applicable Carrier’s computer systems (currently Anthem Blue Cross) to the extent necessary for on-line claims processing, data entry and other related responsibilities.

Ability to accurately interpret plan benefits, process claims, re-calculate claims; performing (sometimes complicated) calculations, applying formulas using multiplication and percentages.

Develop knowledge and understanding of PPO guidelines and procedures, coordination of benefits, Medicare and supplemental plan benefits.

Apply for this great position as a claims department manager today!
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EEO/AA Employer/Vet/Disabled.

The Know Your Rights poster is available here:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf

The pay transparency policy is available here:
https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf

For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.

We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.

AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.
https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf

Founder and CEO, Janice Bryant Howroyd, is a North Carolina native who left her hometown in 1976 armed with $1500. Since then, she has dedicated her efforts to building an organization that is committed to keeping the humanity in Human Resources and Strategic, Inclusive Procurement.

Mrs. Howroyd’s commitment to excellence has grown ActOne Group to 33 countries, with over 17,000 clients and more than 2,800 employees. The largest woman-minority-owned workforce management company founded in the US, ActOne Group professionals bring expertise in delivering corporate HR initiatives to local and global markets.

Mrs. Howroyd was selected by former President Barack Obama to serve as a White House appointee and continues to serve under the current administration as an Ambassador of Energy. Mrs. Howroyd gives generously through funding and advocacy for STEM education, particularly for women and minorities.

Mrs. Howroyd leads her teams to build business success based on the ability to connect great companies with outstanding talent. Her passion for education, mentorship, and self-empowerment initiatives have earned her many professional and philanthropic recognitions. She is a sought–after speaker and media subject matter expert in her fields. Her book, The Art of Work: How to Make Work, Work for You, is available on Amazon.com.