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TPA Medical Claims Manager
Ref No.: 18-00065
Location: Minneapolis, Minnesota
Position Type:Direct Placement
Element Consulting Group has an immediate need for a TPA Medical Claims Manager to join our Client's team in Minneapolis, MN.

Job Description:

Our client is a is a licensed third party administrator that administers self-funded medical and HRA plans for employers. The TPA Medical Claims Manager is responsible for the entire claims experience including; accuracy, quality and turnaround time. The Claims Manager is also responsible for the network and vendor contracts for the TPA.

  • Collaborate across teams to create and deliver an amazing Third Party Administrator claims processing function.
  • Identify improvements to the claims processing experience. This includes implementing and maintaining auto adjudication, quality and turnaround time.
  • Establish processes and procedures to support the claims flow, both within the TPA and across intersections with other areas of the business.  Train and communicate processes as necessary.
  • Oversee claims processing work and dedicated claims examiners/staff to meet service level and contract requirement timelines.
  • Establish processes and audit parameters to ensure claims are approved or denied for payment by ensuring the payment is correct, verifying the proper authorizations were submitted, and resolving any system hold codes.
  • Ensure the TPA is capturing COB savings by coordinating payments of claims between insurance companies when more than one insurance company is involved.
  • Oversee a stop loss claim process to ensure that high dollar claims are reviewed and processed accurately.
  • Manage and oversee all vendor relationships. Partner with the Process Improvement Manager to prioritize and execute the VBA roadmap.
  • Analyze data and report on key metrics related to claims processing, enrollment, payment to providers, vendor utilization and stop loss.
  • Propose solutions to support effective practices and communicate potential areas of risk.
  • Perform occasional day-to-day TPA activities as needed and act as the go-to person for escalated and complex issues that arise.
  • Partner with the Process Improvement Manager to Improve and grow our TPA function as needed and support new business initiatives.
  • Work closely with compliance to ensure all practices meet or exceed regulatory requirement.
  • Work closely with analytics and other departments to provide necessary reporting to support the TPA solutions.

Our ideal candidate is a highly motivated, goal-oriented, team-focused leader who has enough experience with third party administration to establish a new function and lead it successfully.
  • Experience with all facets of a TPA preferred
  • 5+ years claims management experience
  • Medical terminology, CPT, Revenue codes, ICD 9/ICD 10
  • ACA (Affordable Care Act) knowledge and subject matter expertise required
  • Claims processing rules, managed care benefits and auto adjudication
  • Strong technical aptitude and previous experience working with engineering to establish and smoothly operate a claims system.
  • Strong knowledge of all components of insurance claims
  • Previous success establishing workflow and processes.
  • Flexible attitude and ability to develop creative solutions in a fast-paced startup environment
  • Strong communication skills
  • Excellent organizational skills
Candidates authorized to work in the US are encouraged to apply; Element Consulting Group is not sponsoring or transferring work visas at this time.  Due to client requirements, we are not able to work with third party employers on this opportunity.   
Element Consulting Group offers an attractive benefits package including medical, life, dental & vision insurance, health saving account, 401(k) with match and more!