Medical Claims Review Manager jobs in Worcester, MA

Overview

Under the general direction of the Associate Program Director or designee, the Sr Manager, TPL (Third Party Liability) Programs is responsible and accountable for managing TPL program areas, operations, and activities. TPL refers to the legal obligation of third parties, including but not limited to, certain individuals, entities, insurers, or programs to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan. By law, all other available third party resources must meet their legal obligation to pay prior to the Medicaid program paying for the care of an individual, when there is the potential of another liable entity. This position is specifically responsible for operational, program, and contract management oversight of TPL programs and activities. In addition, is responsible for daily operations management of the unit and staff, which provides TPL and coordination of benefits services to MassHealth, the Massachusetts Medicaid program, to ensure that MassHealth is the payor of last resort.

Responsibilities

• Lead and manage TPL programs, operations, and activities, and assist in the implementation of strategic goals and objectives.• Oversee and monitor activities of assigned unit.• Monitor operational efficiencies, and financial outcomes, metrics and benchmarks to provide continuity and ensure program operational success.• Make recommendations for priorities and program implementations.• Make recommendations for improvements to program operations.• Closely monitor the cost savings and revenue activities in the assigned unit to ensure the regular status of the cost avoidance and revenue targets and report on the potential risks for shortfalls or potential gains.• Develop and implement policy, procedure, and program tracking standards in regards to program monitoring and evaluation.• Evaluate and assist in implementing change and ongoing process improvements to increase the efficiency of operations and programs.• Work on TPL cost savings and revenue management projects.• Provide on the job training and orientation for employees.• Develop and implement procedures and guidelines to accomplish project objectives and goals.• Review and analyze data concerning assigned projects in order to determine progress and effectiveness and make recommendations for changes in procedures.• Perform related duties such as attending staff meetings, maintaining records, and preparing reports.• Interact and represent the department on a professional level with the Massachusetts Executive Office of Health and Human Services (EOHHS) and other government agencies. Respond to internal and external entities concerning assigned projects.• Work internally and externally to resolve discrepancies for projects.• Perform other duties as assigned.

Qualifications

REQUIRED EDUCATIONBachelor’s degree in Finance, Public or Health Care Administration, Business, or other related area.REQUIRED WORK EXPERIENCE7 – 9 years of experience in health and human services program management, fiscal management, finance, or public administrationProven skills in financial management or operational management.Thorough knowledge of the federal and Massachusetts state regulations associated with TPL program activities.Thorough knowledge of cost savings and revenue sources for health and human service programs.Experience with contract development and management.Working knowledge of Microsoft Office applications and database management.Strong management and leadership skills.

Additional Information

About Health Care Finance Solutions and Benefit Coordination and Recovery Team