Claims Provider Data Oversight Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee and manage the enhancement of claim outcomes across established and emerging lines of business within the Claims organization.

• Define and influence functional requirements for provider matching logic, Facets claim adjudication procedures, provider data loads and management, provider configuration, and the full claims adjudication process.

• Collaboratively influence claim intake, provider match logic, pre-adjudication, adjudication, post-adjudication, payment procedures, and provider data management.

• Facilitate the translation of business requirements into technical solutions in collaboration with both business and technical teams.

• Partner with Provider Data Management and work alongside business, architecture, and infrastructure teams to maintain service levels and ensure stakeholder satisfaction.

• Lead the implementation of provider data management to achieve appropriate claim outcomes in both new and existing lines of business.

• Identify opportunities for system enhancements, provider matching logic, and data migration requirements; perform end-to-end testing when necessary.

• Analyze data, workflows, policies, and procedures, and propose solutions to support growth initiatives.

• Oversee the analysis of the provider data management process; develop, document, and communicate functional requirements.

• Conduct data analysis, workflow evaluations, and policy assessments to refine provider data loads, enhance operational efficiency, and address complex technology and process challenges.

• Organize work teams, drive consensus, establish project plans, facilitate meetings, and document recommendations and decisions.

• Ensure compliance with industry best practices, regulatory mandates, and contractual obligations.

• Foster a culture of continuous improvement in provider data management and claims processes.

• Drive cross-functional oversight of provider loads and ensure accurate application of business requirements and provider matching logic.

• Perform additional duties as assigned.

⛳️ Requirements

• A Bachelor's degree in business administration, healthcare administration, or a related field, or equivalent years of relevant work experience is required.

• A minimum of three (3) years of progressive experience in provider record data, claims data management, or a related field, including claims outcome analysis, is required.

• Experience with Facets is required.

• Project management experience is necessary.

• Proficiency in the Microsoft Office suite is essential.

• A proven track record of successfully implementing new managed care products is required.

• Ability to manage a variety of complex projects and processes to completion.

• Expert understanding of claims processes, Facets, pre-adjudication, post-adjudication, Checkwrite, Mass Claims Adjustments, Batch Processing, Remittance Advice process, reimbursement methodology, and project management toolsets.

• Outstanding written and verbal communication skills are essential.

• Strong relationship management and collaboration skills are necessary.

• Effective listening and critical thinking skills are required.

• Strong analytical and problem-solving abilities are needed.

• Project Management Professional (PMP) certification is preferred.

• General office environment; may require sitting or standing for extended periods of time.

• Occasional travel may be necessary based on business needs.

🏝️ Benefits

• Bonus tied to company and individual performance may be available.

• Substantial and comprehensive total rewards package.

• Equal Opportunity Employer fostering an environment of belonging that welcomes and supports individuals of all backgrounds.