Manager, Health Plan Claims

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Provides analytical, technical and administrative support relative to claims processing and payment. Interacts with key contacts relative to claims services; assist with self-administration program development. Provides supervision and administrative oversight in health plan claims processing unit. Coordinates processing of high dollar claims, subrogation efforts, and act as primary contact for stop loss. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment.

Job Requirements:

Education and Work Experience:

• Bachelor's Degree or equivalent combination of education/related experience: Required
• Master''s Degree: Preferred
• Five years'' health plans claims examiner experience: Preferred
• One year''s leadership experience: Preferred

Essential Functions:

• Serves as lead technical resource. Is responsible for appropriate claims adjudication per plan guidelines. Provides supervisory oversight and claims processing as necessary. Processes all claims in excess of $50,000 which includes external review processing. Provides administrative oversight on third party reimbursement and escheatment procedure.
• Reviews unavailable service forms for approval, handle case management, utilization review, and provider referrals as needed. Reviews and adjudicate any appeals at Level One and participate in Appeals Committee for Level Two.
• Negotiates with providers per high dollar procedures and in consultation with AVP and is able to administer hospital and physician contracts. Handles subrogation case upon litigation in conjunction with vendor specialist.
• Monitors potential stop loss claims, ensures notice to stop loss carrier, and ensures submission for reimbursement of any claims exceeding stop loss.
• Provides technical assistance to plan interpretation, coverage determinations and other coverage issues as they arise. Provides staff with interpretation of plans and amendments after review with AVP. Provides training as needed. Audits established claims examiners claim payments.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God''s love by inspiring health, wholeness and hope.