• Review and implement efficient and effective processes with regards to claims processing, including increasing or maintaining auto adjudication rates, operational activities such as encounter data submission, check run oversight, accurate provider loading, fee schedules and development and maintenance of claims queries and reporting.• Ensure claims are processed within regulated timeframes and according to all Medicare regulations and HMO contracts / DOFR. • Coordinate plan audits, DOFR. • Produce and review examiner productivity reports.• Create and conduct corrective actions as required.• Maintain and oversee the claims system software and other related software to confirm proper functionality and ensuring it meets the needs of the department. • Act as the lead for system related projects (e.g., system review and rebuild, new business implementation, etc.). • Responsible for the oversight and/or hands on of the set-up and intake of EDI for inbound claims and the development of outbound EDI.• Work with the Claim Auditor to identify areas of opportunity at a high level for training, as well as on an individual basis, to ensure that team is functioning to the best of ability.• Ensure all required member communications are in place and monitor phone interactions with members and providers.• Oversight of the Customer Service Representatives, Claims Representatives, Claims Processors, Application Specialists, and other operational oriented roles.• Determine the need for new policies by identifying issues, which require clarity and create and author policy. • Process over-payments and refunds

• Assist with migration and upgrade testing and validation of data.• Maintain a variety of system setup functions in proprietary claims management software which includes payer, provider, claims and user security data.• Process claims for new client and audit and prepare the weekly check run.• Create and update Auto Adjudication Rules.• ICD-10 testing with internal staff and external clients.• Assist with streamlining processes for EDI errors and claims processing.• Correct EDI errors and load the data into the claims system.• Troubleshoot problems in EDI transmissions due to setup/system/map errors and correct.• Apply appropriate maps for inbound and outbound transmissions.• Advise staff of system capabilities and functions.

• Assist with the transmission and receipt of HIPAA standard EDI transactions (including 837, 835, and 999) and act as the primary production support role as well as new EDI process development.• Maintain a variety of system setup functions in proprietary claims management software which includes payer and provider data.• Troubleshoot problems in EDI transmissions due to setup/system/map errors and correct in real time or report to appropriate staff to correct.• Apply appropriate maps for inbound and outbound transmissions.• Assist business users with production EDI tasks and communicating with business units to resolve EDI issues.• Work with software vendor(s) to improve efficiencies in EDI file transmissions and various follow-up tasks through system automation or new work flow processes.• Assist the Claims department with system setup and improvements for streamlined claims processing as well as large re-pricing projects.• Assist other departments with data cleanup within the proprietary claims management software.• Add providers, Procedure codes, Modifiers as needed.• Coordinate and assist Analytics with report setup and functionality to ensure accurate reports.

• Generate and send monthly 837 encounter transmissions after correcting any non-compliant errors.• Audit and transmit 835 files for 7 clients multiple times a week.• Assist in implementing HIPAA 820 transactions through the Market Place.• Perform Compliance and upgrade testing for HIPAA transactions 837,834,835 and 820.• Set up Trading Partners for the 820 transactions.• Research data requests for the Claims and Provider Maintenance departments and respond for accurate claims processing.• Work with the clearinghouse regarding accuracy and frequency of transmissions and reports.• Created tracking spreadsheets of clearinghouse claim rejects and provide the data to management for review.• Complete claim tracking reports from the clearinghouse for each client.

• Audit weekly check runs for 5 medical groups processing HMO claims.• Provide expertise and/or general claims support to teams in reviewing, researching, processing and adjusting claims • Authorize appropriate payment or refer claims to investigators for further review • Analyze and identify trends and provides reports as necessary • Consistently meet established productivity, schedule adherence, and quality standards • Supervise, monitor, track and direct day to day operations to staff • Coordinates, supervises and is accountable for the daily activities of business support, technical or production team or unit. • Oversee all Electronic claims received via multiple Clearinghouses for 13 IPA's and OAO Health Care Systems EZNET for 12 business partners.• Work closely with the Director of IT to implement, test, and troubleshoot new system upgrades and to resolve any issues that may arise