Reconciliation DB Claims Manager

Job purpose : The Reconciliation DB Claims Manager is responsible for overseeing and managing the Reconciliation process within the organization. To ensure that financial transactions and records are accurate and consistent, and that any discrepancies are identified and resolved in timely manner. Key Responsibilities

• Reconciliation review process : The Reconciliation DB Claims Manager is responsible for establishing standardized reconciliation review procedures and guidelines. Ensuring that reconciliation files from providers are received, logged, and maintained. These files will have to be reviewed by the team following the defined processes and summarized as per the agreed format within the stipulated timeframes.
• Claims Administration activities: The Reconciliation DB Claims Manager is responsible for the claim administration activities of claim registration / upload into the system, ensuring all posted regulatory claims are available for processing, and the management of the remittance advice upload process.
• Team Leadership : Supervise and provide guidance to the claims reconciliation team. Ensuring that they understand their goals, responsibilities, and perform their tasks accurately and efficiently.
• Continuous Process Improvement : The Reconciliation DB Claims Manager is responsible for driving continuous improvement initiatives within the reconciliation unit. Continuously evaluate the reconciliation process and identify areas for improvement. Implement enhancements to streamlines processes, automate repetitive tasks, and reduce the risk of errors or gaps.
• Discrepancies Identification and Resolution : Identify discrepancies during the reconciliation process and investigate their causes. Take appropriate actions to resolve discrepancies, which may involve collaborating with other departments and stakeholders.
• Reporting : Prepare regular reports on the reconciliation activities, including outstanding items, aging analysis, and resolution status. Present these reports to the Senior management highlighting significant issues or trends.
• Compliance and Audit : Ensure that the reconciliation process sticks to industry regulations, internal control standards, and audit requirements. Collaborate with internal and external auditors during audits and provide necessary documentation and explanations.
• Stakeholder Management : Cooperate with various stakeholders, such as finance, underwriting, claims, external providers. Ensuring smooth reconciliation processes and resolve any issue or dispute in a timely manner.
• Continuous Monitoring : Continuously monitor the reconciliation process, track the KPIs of the reconciliation unit, and implement proactive measures to maintain accuracy and efficiency of the reconciliation unit.
• Exception Handling : During the reconciliation process, exceptions or discrepancies may arise. The Reconciliation DB Claims Manager is responsible for defining the protocols and escalation procedures for handling these exceptions. Coordinate with relevant stakeholders to resolve exceptions promptly and ensure that appropriate actions are taken to prevent similar issues in the future.

• Reconciliation Process & Workflow Management : The Reconciliation DB Claims Manager is responsible for the overseeing the day-to-day operations of the reconciliation unit, design, and implement workflow processes to ensure that all reconciliation activities are executed accurately, efficiently, and in compliance with established policies and procedures. Allocate resources effectively, prioritize tasks, and monitor the progress of reconciliation activities to meet instituted deadlines.
• Remittance Advice : The Reconciliation DB Claims Manager is responsible for ensuring that all the processed claims are remitted to the regulatory post office post the payment. This includes manual upload of failed / exception cases and regular reporting on RA status.
• Quality Control : The Reconciliation DB Claims Manager implements strong control measures to ensure the accuracy and completeness of reconciliation activities. Establish review processes to validate the work performed by the reconciliation team, conduct periodic audits, and perform sample checks to identify any errors or deficiencies. Provide feedback and training to enhance the team’s performance and stick to the quality standards.
• Reconciliation Tools : The Reconciliation DB Claims Manager responsible for evaluating, implementing, and maintaining reconciliation tools. Collaborate with the IT department on any system issues related to the process or data (as it pertains to reconciliation). Ensuring the reconciliation team is trained on the effective use of the tools and systems.
• Data Analysis and Reporting : The Reconciliation DB Claims Manager utilizes data analysis techniques and reporting tools to monitor reconciliation activities, identify trends, and generate relevant reports. Present these reports to the senior management to make informed decisions.
• Data Governance and Security : The Reconciliation DB Claims Manager ensures the integrity, confidentiality, and security of financial data used in the reconciliation process. Establish data governance policies and procedures. Implement access controls, and monitor compliance with data protection regulations.

• 5 Years’ experience in the medical and/or insurance field(s) required.
• 2-3 Year’s in management/team leadership role
• In depth knowledge of health insurance industry best practices.
• Detailed understanding of the claim cycles & processes.
• Familiarity with coding systems (CPT, ICD-10, HCPCS) and medical billing procedures.
• Previous knowledge in medical processing.
• Demonstrated ability to collaborate effectively with cross-functional teams.