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The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices. 

What You Will Do
This position manages the claims units for Sharp Managed Care Contracts. This includes but is not limited to claims for Sharp Rees-Stealy, Sharp Community Medical Group, and claims for EOHD, Clinical Trials, and Transplant services paid by Sharp HealthCare. This position is responsible for prompt, accurate, and efficient processing of claims.

Required Qualifications

• 3 years' experience in the HMO industry to include claims, customer service, and/or health insurance management.
• 2 years leadership experience.

Preferred Qualifications

• Experience with EPIC Tapestry.

Other Qualification Requirements

• Bachelor's degree in business, health services, management, or relevant field; or 4 years of relevant experience in the healthcare industry may substitute for the degree. - REQUIRED

Essential Functions

• Leadership
  Display professionalism and teamwork in promoting the Mission, Goals, and Objectives of Sharp Healthcare.
  Recruit, hire, motivates staff to perform at a level that consistently meets expectations.
  Develop, train, counsel staff, and conduct performance appraisals.
  (Standard: Employee turnover rate kept at or below corporate standard and complete performance appraisals in a timely manner 98% of the time.
• Daily Operations
  Manage the daily operations of the claims department maintaining claim turnaround times at 95% processed within four weeks, 95% of the time, and maintaining accuracy rates of 95% procedural and 98% financial.
  Develop reporting and follow through mechanisms to document departmental efficiency and productivity.
  Responsible for the development and implementation of continuous quality improvement and measurement of claims unit effectiveness.
• Training
  Coordinate continuing staff training and establish quality and productivity standards to be reported monthly.
  Provide input into claims policy and procedure manuals.
  Effectively communicate departmental policies to staff and other affected areas.
• Application Management
  Participates in the development and implementation of improvements in software functionality, workflow and system integration.
• Internal and External Customer Service
  Interface with Health Plans, Providers, Members, and Medical Groups to resolve issues in a professional manner that maintains consistently positive relationships. Demonstrate a positive, professional and contributory posture in all matters requiring interface with customers, both internal and external.
  (Standard: Consistent positive feedback from staff, peers, and external customers. Less than 2 exceptions noted per year).
• Safety
  Demonstrate safe work practices by identifying and reporting potential safety hazards to appropriate personnel, including but not limited to the following: Assuring staff’s appropriate chair height, keyboard and screen placement, securing of electrical wiring, use of proper body mechanics, etc. Attend annual Safety Fair.
  (Standard: 1 exception noted per year and attends annual Safety Fair).

Knowledge, Skills, and Abilities

• Knowledge of health insurance or HMO operations with emphasis on claims.
• Excellent organizational and interpersonal skills.
• Ability to work effectively as a member of a creative management team.
• Adept at being an initiator of positive change to support the Mission, Values, and Goals of Sharp Healthcare.
• Excellent analytical skills and understanding of data base management.
• Knowledge of claims coding system, claims auditing techniques, and claim software functionalities.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class