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Manager, Systems Management

Manager, Systems Management

Job Locations 
US-VA-Glen Allen
Job ID 
2018-4466

Job Description

Overview

The Manager will be a key member of the department’s management team and will play a critical role in the management of the company’s core claims platform (s) and editing and pricing systems.  He/she will provide vision and direction on activities related to the benefits requirements used to configure the processing platforms and/or third party applications; testing and validation of the configuration and monitoring activities such as payment validation and modeling.

 

In addition, this individual will work with various levels of management on project planning, gathering business requirements and coordinate activities related to system upgrades, system development and others corporate initiatives. 

 

The Manager will influence testing strategies related to system platform migration, upgrades and staffing development and will be responsible for resolving system related issues. He or She should be proficient in analyzing business needs, determining necessary configuration, managing projects and developing test scenarios to ensure accurate and complete testing. The manager will be responsible for ensuring that the team complies with all regulatory and business process requirements.

Responsibilities

  • Lead requirements development sessions with business owners and other team members
  • Manage activities related to systems configuration, documentation and support various claims applications
  • Manage work assignments/duties to ensure smooth interdepartmental operations in the area of configuration, automation and analysis
  • Oversees the verification and implementation of new requirements received from Medical Management, Network Development, State and Federal mandates
  • Monitor process of creating and conducting analysis to enhance overall Claims Operations and systems performance
  • Evaluate scope and impact of identified solutions. Identify project timelines and milestones and ensures deadlines are met. Recommends and obtains approval for appropriate solution(s) for implementation
  • Ensure that established processes/procedures are followed as designed
  • Define system requirements, process flows, and interfaces based on business needs
  • Make recommendations regarding continuous improvement of claims department, work processes and operating procedures
  • Analyze, interpret and summarize data in preparation of statistical and analytical reporting
  • Develops and manages departmental policies and procedures for benefits loading and system configuration, including manuals used to train new employees and cross training of current employees
  • Monitors and tracks staff performance relating to service level agreements and departmental standards
  • Hire, train, develop and appraise staff effectively. Take corrective action as needed on a timely basis and in accordance with company policy
  • Directs the research and resolution of all systems reimbursement/coding.
  • Perform audits and provide guidance specific Payment Integrity tasks to ensure that reimbursement provisions are applied according to contractual & non-par specifications for new and existing reimbursement programs.

Qualifications

MINIMUM EDUCATION REQUIREMENTS

 

  • Bachelor’s degree in Computer Science, Business Administration, Information Systems, Health Administration or related field required.

SPECIAL KNOWLEDGE AND/OR SKILLS

 

  • Working knowledge of managed Medicare and Medicaid claims payment methodologies in a TPA, HMO or hospital setting
  • Ability to comprehend and interpret provider contracts, regulatory payment methodologies, etc.
  • Knowledge of CPT, ICD-9/10 and HCPCS coding system
  • Ability to make proper decisions quickly  and complete complex projects
  • Proficient knowledge of Microsoft Office (Excel, Word & Access)
  • Proven technical ability with Microsoft SQL Server 2005 - 2008 (T-SQL, SSIS, SSRS)
  • A team player who mangers multiple projects simultaneously in a fast paced environment
  • 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.
  • Excellent written and oral communication skills
  • Experience in supervision, team-building, problem-solving for complex claims configuration or troubleshooting Claim systems preferred
  • Knowledge of Medicare Part A and Part B processing with concentration on facility reimbursement methodologies for inpatient and outpatient claims
  • Knowledge of CMS & Medicaid regulatory guidelines related to claim payments and other Federal requirements.
  • Knowledge of CPT-4 and ICD-9 coding; understanding of Medicare’s Correct Coding Initiative (CCI)

WORK BACKGROUND/EXPERIENCE

 

  • Minimum of 5 years working in Information Systems managing and supporting applications or with health claim data  
  • Minimum of 3 years experience in business process re-engineering and improvement
  • Minimum 2 years experience in technology field in management/supervisory level of responsibility.    
  • Minimum 2 years of supervisory or managerial experience in Claims Operations environment.
  • D-SNP, Medicare Advantage, or Medicaid Experience a Plus. 
  • Trizetto QNXT systems experience a plus.

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

 

About Us

Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

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