The Claims Manager at MSO, Inc. of Southern California leads the Claims Department, overseeing a small team to ensure accurate and timely adjudication of managed care claims, primarily Medicare and Medi-Cal. Reporting directly to the CEO/President and Compliance Officer, this remote position requires expertise in regulatory compliance and claims processing within a healthcare management environment. Southern California residency is preferred for occasional on-site meetings.

Responsibilities

Supervise and develop a small claims team of 1-5 staff
Ensure accurate, timely adjudication of Medicare, Medi-Cal, and Commercial claims
Train claims staff and support ongoing professional development
Prepare and submit detailed Claims Timeliness and Health Plan reports with proof of submission
Manage provider and Health Plan appeals and oversee payment recovery processes
Coordinate claims audits and corrective actions with Health Plans, auditors, and providers
Develop and update departmental policies, procedures, and process improvements
Create performance reports to monitor staff metrics and identify training needs
Support electronic claims submission integration, system upgrades, and auto-adjudication enhancements
Collaborate with Provider Services on provider, vendor, and contract data management
Communicate regularly with executive leadership and clients regarding claims status and issues

Required Qualifications

Some college coursework
Minimum five years medical claims adjudication experience in managed healthcare
Proficiency in ICD, CPT, and HCPCS coding
Strong knowledge of DHCS, DMHC, CMS, and Health Plan regulations for Medi-Cal, Medicare, and Commercial claims
Definitive understanding of provider and Health Plan contracting and reimbursement methodologies
Proficient Excel and computer skills
Strong verbal and written communication skills
Analytical and problem-solving abilities
Effective team leadership and supervisory experience

Company Description

see website www.msosocal.com

MSO, INC. OF SOUTHERN CALIFORNIA

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CLAIMS MANAGER