Medical Claims Review Manager jobs in Miami, FL

**Position is fully onsite Mon-Friday, Bilingual in Spanish is required**

Location: 9250 NW 36th St, Miami, FL 33178

About us:

Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked, and each employee is valued.

Position Summary:

The Claims Manager is responsible for the oversight of Solis Health Plans internal claims process, the oversight and other vendor services with a focus on the review of processed claims prior to remuneration. This position will also be responsible for claim-based projects including researching, resolving discrepancies, and developing processes for improvement as necessary.

Key Responsibilities:

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation; including, but not limited to:

• Configure, implement and administer a robust claims quality and auditing program.
• Establish best practice claims payment methodology based on current CMS claims payment regulations.
• Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internal system and beneficiary impact.
• Coordinate with Network Services and Provider Relations teams to ensure proper reimbursements.
• Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment.
• Conduct pre-pay and post-pay audits to verify accurate claim payments and/or denials.
• Provide exceptional service to providers, internal and external customers in accordance with Company values.
• Forecast all staffing requirements, schedule workforce accordingly.
• Complete regular review of internal reporting (ex., high dollar claims).
• Ensure regulatory compliance, quality and efficiency.

• Participate and support ad-hoc audits as required.
• Collaborate with Utilization Management Team as necessary.
• Complete all assigned claim projects.
• Daily review of claims Inquiry.
• Maintain KPI’s counts for reporting purposes.
• Analyze monthly CMS reports.
• Create cases for work disputes received from claims inquiry or claims fax.
• Oversee all inquiries that come in from either member services or providers with questions, claims statuses, EOP’s.
• Oversee Unified Portal for any requests that member services send to claim for further assistance.
• Reviewing of itemized bills and reviewing cases with UM team.
• Review correspondence received from Insurance Companies or Attorney Offices.
• Generate letters to advise if claims on file along with spreadsheet of payments made.
• Work with Quality and Compliance Department on claims audits as required.

Qualifications

• Strong working knowledge of claims processing standards, CMS claims processing requirements and various Medicare fee schedules.
• Knowledge of automated claims processing systems and other complex claim processing rules and regulations.
• Proficient in processing / auditing claims for Medicare plans.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations.
• Position may require flexible hours, unscheduled overtime or occasional week-end work.

Education:

Experience:

• 2 years’ experience with complex claims processing and/or auditing within the health insurance industry or medical healthcare delivery system.
• 2 years’ experience in a managed healthcare environment related to claims processing/auditing, including Medicare plans.
• 2 years’ experience with CMS requirements, and other complex claim processing rules and regulations.
• 2 years’ experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes.
• Recent Institutional and Professional claim payment experience.

What Set Us Apart

Join Solis Health Plans as a Healthcare Claims Manager and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!