Responsibilities
Supervise Balance Billing Department staff in accordance with established departmental procedures, Human Resources guidelines, and provisions of the Collective Bargaining Agreement, as appropriate; monitor and process staff time and attendance via timekeeping system (ADP)
Evaluate employee performance related to attendance, productivity, and workflow adherence; provide ongoing coaching, feedback, and corrective action when necessary. Identify training needs and develop performance improvement plans to enhance staff effectiveness and engagement.
Collaborate with management to develop, revise, and implement policies, procedures, and workflows to ensure compliance with internal standards and external regulations.
Assist in overseeing No Surprise Act open negotiations and Independent Dispute Resolution processes, ensuring strict regulatory timelines and accuracy standards are met.
Provide guidance to staff on complex claims, including review and approval of payments exceeding staff thresholds and system updates in accordance with Fund policies.
Proactively negotiate claims impacted by the No Surprises Act, focusing on resolving disputes with out-of-network providers to avoid escalation to Independent Dispute Resolution. This includes leveraging communication and negotiation strategies to achieve mutually agreeable payment solutions.
Assess claim details and potential outcomes to determine when negotiation is more beneficial than escalating to Independent Dispute Resolution, utilizing various benchmarks.
Assess and resolve all No Surprises Act staff claims inquiries
Monitor daily, weekly, and monthly production, aging, and escalation reports to ensure timely and appropriate action.
Assist in developing and maintaining No Surprises Act reporting structures, tracking key metrics such as settlement rates, Independent Dispute Resolution escalation, and compliance indicators; Prepare and present quantitative and qualitative reports to management highlighting trends, performance gaps, and opportunities for improvement.
Manage updates to BeneFAQ topics to ensure accurate
Oral and written communication with members, providers, attorneys and/or collection agencies regarding payment status and other status of inquiries by drafting various confirmation, correspondence, and resolution letters
Perform additional duties and projects as assigned by management
Qualifications
Bachelor's degree in Business Management, Health, or relevant years of experience required
Minimum three (3) years' experience within claims processing department with in-depth knowledge of medical claims processing, medical terminology in a healthcare benefits environment; to include one (1) years' experience in a leadership role required
Strong management and leadership skills required; ability to coach, mentor, motivate staff; generate and implement improvement plans; address staff training needs
Excellent math skills and the ability to translate mathematical information into concise reports
Ability to conduct various data comparison analysis, working knowledge of macros, tables, forms, queries and reports a must
Excellent knowledge eligibility rules, Coordination of Benefits, and 1199SEIU Benefit and Pension Fund benefits and Funds systems (QNXT, DMS V3, RightFax); experience with fee negotiations and settlements; knowledge of balance billing, Fair Health, BeneFAQs, No Surprise Act preferred
Demonstrate strong analytical, organizational, problem-solving and time management skills; ability to multi-task and meet operational deadlines
Intermediate skill level with Microsoft Access, Excel and Word required; knowledge of PowerPoint and Access preferred
Excellent research, interpersonal, oral and written communication skills
Able to work well under pressure and prioritize work with tight deadlines in a high-volume environment
Supervisor • New York, NY, United States
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