Claims Quality Audit Manager jobs in Dallas, TX

The Claims Manager plays an integral role at Blackhawk Claims Services by maintaining a balance between customer satisfaction and cost control by overseeing the claims processing team and ensuring that the workflow is efficient, accurate, and timely in handling and settlement of claims. This is a hands-on working Manager role that involves coordinating with the policyholders, analysts, and other stakeholders to facilitate a smooth process from claim initiation to resolution. Monitors the performance of the claims team, provides feedback and coaching, and implements policies and procedures to improve quality and productivity. To effectively process claims, we count on our managers to provide expert input regarding our day-to-day procedures. They should feel comfortable both giving orders and soliciting feedback to get a better sense of the daily challenges. Our managers may also be tasked with handling customer disputes, working on complex cases, and determining revenue goals based on past performance.

Company Profile:

Blackhawk is focused on delivering an excellent customer experience with our robust suite of services to meet your claims administration needs. Our TPA serves national and regional clients seeking cost effective and trusted claims and health management services. Our leadership team provides the experience and expertise our customers need to manage their claims administration. Blackhawk is committed to providing efficient claims analysis and developing tailored solutions for your business. All while providing an unparalleled, exceptional customer experience.

Job Duties:

Primary Responsibilities

• Manage the daily operations of the claims processing team of Medical Claims Analysts also known as Claims Adjudicators/Examiners by overseeing the administration of health insurance claims, payment processing, billing research, and responding to inquiries, including assigning tasks, setting priorities, and resolving issues with the Claims Team.
• Ensures claims are accurate and timely disposition and resolves matters according to coverage amounts and company procedures. Working with the leadership team to adjust procedures and policies as needed. Adjusting protocols based on company needs.
• Working Manager who also guides the team on more complex, or high-value claims and settling. difficult claims issues and provide solutions and recommendations. Reviews and resolves escalated issues, by handling and processing official paperwork while ensuring legal compliance with the claims process.

• Analyze and report on the claim’s workload, productivity, and quality metrics, and identify areas for improvement.
• Ensure compliance with all internal and external policies, regulations, and standards related to claims processing, such as HIPAA, CMS, and state laws.
• Provide leadership, guidance, and support to the claims staff, and foster a culture of collaboration, accountability, and excellence.
• Collaborate with other managers and stakeholders across the organization, such as IT, finance, customer service, and quality assurance, to ensure alignment and integration of claims processes and systems.
• Conduct regular performance reviews, feedback sessions, and coaching for the claims staff, and address any performance or behavioral issues. Building and motivating the team to hit productivity goals.
• Coordinate and facilitate training and development programs for the claims staff and ensure that they are updated on the latest industry trends, best practices, and system changes.
• Manage and oversee the budget, resources, and equipment for the claims processing team, and ensure that they are adequate and efficient.
• Attending educational sessions in the event of new laws or changing business directives.

• Bachelor's degree in business administration, health care management, or related field, or equivalent work experience.
• A minimum of five years of experience in processing medical claims is generally required, preferably in a healthcare or insurance organization.
• Minimum of three years of experience in managing or supervising a claims processing team.
• Strong knowledge of claims processing systems, workflows, and in-depth understanding of legal regulations.
• Proficient in Microsoft Office, especially Excel, and other data analysis tools.
• Excellent communication, interpersonal, and leadership skills. Ability to motivate, coach, and develop a high-performing team.
• Ability to work under pressure, multitask, and prioritize in a fast-paced environment.
• Excellent analytical and problem-solving with the ability to analyze data, identify problems, and provide solutions.
• Excellent organizational skills, advanced analytical, problem-solving, and critical thinking skills.
• Results-driven, action-oriented, self-motivated mindset, quality-focused, and the ability to organize, document, and control both digital and physical data.
• Demonstrates a commitment to achieve all goals and objectives, including driving operational and performance metrics and how to provide targeted feedback.
• Detail-oriented approach with a strong drive for excellent customer service, continuous improvement, and experience measuring and reporting on business impact of projects and initiatives.
• Excellent written, and verbal communication skills and interpersonal skills to engage, collaborate, and work with cross-functional teams and multiple stakeholders.
• Must have a practical mind to solve problems on the spot partnered with an ability to see the big picture and make improvements.
• Provides hands-on support at all levels to ensure successful implementation of change initiatives.
• Excellent emotional intelligence, positive, patient, and proven demonstrable leadership, management, and motivational skills.
• Must be experienced and comfortable working in a dynamic entrepreneurial environment and able to deal well with change and ambiguity.

Preferred Skills & Qualifications:

• Working for TPA is strongly preferred.
• At least 3 years of experience as an Insurance Claims Manager
• Formal legal training or certification