Lumeris Manager, Claims Quality Assurance in St. Louis, Missouri
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Manager, Claims Quality Assurance
The Manager, Claims Quality Assurance will be responsible for overseeing testing, implementation and validation/monitoring for new client and product implementations. In addition, the Manager will also be responsible for all aspects of claims pre/post-payment monitoring and reporting. He/she will work closely with the Manger of Claims and Manager of System Configuration to develop reports, perform root cause analysis and identify areas of improvement including but not limited to training opportunities. The Manager will manage the Claims Test Pro application and/or interfaces used to support claims testing, implementation, validation and departmental reporting. The Manager will also be responsible for developing staff, documenting processes and procedures to support business needs. The Manager will implement a change control process to enforce a strict change management policy and a clear documentation process.
Manages Claims Test Pro and support all claims applications as it relates to testing, implementation and validation/monitoring
Develop, maintain and enforce strict change control policy for system configuration changes; ensure established processes/procedures are followed as designed
Make recommendations regarding continuous improvement of Claims Operations, work processes and operating procedures; creation of process maps and supporting documentation for such procedures and/or processes
Hire, train and develop staff effectively. Take corrective action as needed on a timely basis and in accordance with company policy
Develop and maintain departmental performance reports and dashboards; develop, analyze, interpret and summarize data as it relates to claims monitoring and post validation results
Bachelor's degree in Computer Science, MIS, Business or related field OR equivalent experience
Minimum of 5 years working in healthcare operations, preferably Claims, IT or Audit role
Systems/application configuration experience, including testing, implementation and validation/monitoring
Experience in supervision, team-building and problem-solving
Excellent interpersonal skills, including the ability to work with all levels of personnel including, but not limited to peers and Senior Management within the organization
Strong analytical skillset; demonstrated ability to think outside of the box
Knowledge of CPT, ICD-9/10 and HCPS coding system
Proficient knowledge of Microsoft Office
Strongly Preferred Skills:
Experience working with and knowledge of Medicare and/or Medicare Advantage programs
Quality assurance or Auditing background
Experience with Facets claims software
Working knowledge of SQL in order to read code
- While performing the duties of this job, the employee works in normal office working conditions.
- The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
Lumeris is an EEO/AA employer M/F/V/D.
St. Louis, MO
Join Our Growing Team!
Lumeris is a value-based care managed services operator for health systems and providers seeking extraordinary clinical and financial outcomes. Lumeris aligns providers and payers across populations with technologies, processes, behaviors and information to achieve high-quality, cost-effective care with satisfied consumers — and engaged physicians.
Lumeris with Essence Healthcare, its inaugural client and learning laboratory with more than 60,000 Medicare members in Missouri and Illinois, has averaged a CMS rating of 4.5 Stars for the last ten years and produced the highest consumer and physician satisfaction scores in the industry along with significantly better clinical outcomes and lower costs. For more information, go to www.lumeris.com.
Why Join Lumeris?
At Lumeris, you will be part of team that is focused on solving the nation’s healthcare problem, and you will be able to contribute to our purpose. Our environment is fast-paced, change-oriented and focused on growth and employee engagement. At Lumeris, we know that talent is best utilized when given the opportunity to succeed. That is why we have removed the boundaries that inhibit success and focus on fostering an environment that allows employees to utilize their talents.