Manager of Claims Management

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Brief Job Description:

This position performs highly advanced (senior level) managerial work in the Claims Management unit in the Provider Services section of the Medicaid and CHIP Services Division. This position will oversee work with Medicaid providers regarding claims, recoupments, appeals, and reconsiderations. Responsible for management of day‐to‐day personnel and operations of this unit including performance evaluations, training, and hiring/termination of staff. Develops Claims Management unit goals and objectives. Oversees work assignments including activities for collecting Medicaid provider overpayments, managing the vendor hold and release function, overseeing the collection of Medicaid recipient third party resources for long term care, reviewing administrative appeals for acute care, and overseeing fee-for-service (FFS) claims processing performed by the Texas Medicaid and Healthcare Partnership (TMHP). Represents the unit in meetings, legal matters, workgroups, hearings, and with other governmental agencies. Serves as subject matter expert, directing development of policies, guidelines, and procedures produced by the unit and responding to technical inquiries regarding unit policies and procedures. Oversees and participates in major agency projects that impact the unit. Duties are performed under limited supervision, with extensive latitude for the use independent judgement.

Essential Job Functions (EJFs):

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

Personnel Management – Interviews, hires, manages, conducts, and oversees staff training. Provides staff with work assignments, direction on responsibilities, information on performance expectations, and feedback. Conducts performance evaluations. Keeps staff informed about relevant departmental activities and decisions. Provides staff with tools and information needed to complete their responsibilities. Monitors staff attendance, reviews and approves leave and carries out other human resources activities. Recommends personnel actions and works with management and human resources as needed. (20%)

Operational Management – Manages the day‐to‐day operational activities of the Claims Management staff and their assigned activities to include recoupment of Medicaid provider overpayments; administration of vendor holds and releases; review of administrative appeals; oversight of third-party resource collections performed by TMHP; and claims processing performed by TMHP. Ensures unit policies and procedures are accurate and up to date; ensures effective evaluation tools are designed to measure the progress towards meeting the goals and objectives of the program, and meeting service levels. Develops goals, objectives, and efficiencies for the unit’s operations. Ensures unit operations are aligned with agency and division strategic goals. Develops, plans, and approves priorities and standards for achieving goals. Reviews and manages the unit’s work inventory including creating and tracking productivity reports. Assesses program activities to identify process improvements, efficiencies, monitoring, and automation opportunities. Reviews and approves budget requests. Provides updates to management for key issues. (30%)

Technical Support – Represents the unit in meetings and projects that require expertise about the unit’s functions. Provides technical support to staff on complex cases and works with other leaders across the agency to address blocking issues. Oversees and conducts complex research and analysis. Leads and participates in projects and workgroups, coordinates with Texas Medicaid contractors, and other program areas, making decisions as necessary on technical and programmatic issues and responding to inquiries regarding business policies and procedures. Makes presentations and provides information to program areas and stakeholders. (35%)

Project Management – Participates or manages the successful implementation of projects and initiatives affecting Claims Management including the review and approval of project deliverables, resources, testing, and other project management activities. Assigns and oversees staff participating in projects affecting the unit. Coordinates and leads cross‐functional projects affecting Claims Management with major programmatic impacts. (15%)

Knowledge, Skills and Abilities (KSAs):

• Knowledge of accounting principles.
• Knowledge of debt collection practices including bankruptcies and settlements.
• Knowledge of healthcare claims processing systems.
• Knowledge of state and federal rules, regulations, policies, and program requirements related to Medicaid or Medicare.
• Supervisory and leadership skills.
• Customer service skills.
• Ability to reconcile complex financial information.
• Ability to articulate business user requirements for information technology systems and perform user acceptance testing.

Registrations, Licensure Requirements or Certifications:

N/A

Initial Screening Criteria:

Graduation from an accredited four‐year college or university. Experience and education may be substituted on a year-for-year basis.

Three years’ experience in claims payment, claims processing, or financial collection activities.

Preferred:

Experience as a supervisor, team lead, or project lead strongly preferred.

Experience working in HHSC or Medicaid programs preferred.

Knowledge of accounting principles preferred.

Experience responding directly to customers regarding claim issues preferred.

Direct customer service experience, such as call center experience, preferred.

Additional Information:

Any employment offer is contingent upon available budgeted funds. The offered salary will be determined in accordance with budgetary limits and the requirements of HHSC Human Resources manual.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.