The Polyclinic

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Claims Manager - Physician Care Network (PCN)

at The Polyclinic

Posted: 11/20/2019
Job Reference #: *0DE29936465A1EB5
Keywords: operations

Job Description

Requisition Number

Post Date

Claims Manager - Physician Care Network (PCN)




Hours: Full Time; Monday - Friday; 8:00 - 4:30
Location: The Polyclinic 1145 Broadway


Plans, organizes and manages all operations, applications and interfaces used to support the claims processing operations of Physicians Care Network. Works directly with claims, customer service, system and EDI analysts, overseeing the planning and coordinating of all activities as they relate to the claims operations departments, including collaboration with the IT Director for systems installations, upgrades, and system support. Improve efficiencies and workflows within operations, oversee processes and procedures to support business needs and diagnose claims systems issues, and manage systems configuration and documentation, and recommends appropriate solutions for implementation.


  • Collaborate with the IT Director to manage EZCAP computer system.
  • Manage claims processing operations including production processing, all recovery activities, training, auditing and procedure development and staff assignments to ensure continued delegation and meet required performance standards.
  • Establish continuous improvement processes to raise service levels and increase efficiency.
  • Interact with care management in a problem solving capacity to improve quality and ensure appropriate and timely complex claim resolution.
  • Manage business aspects of claims processing software including system configuration, fee schedule development, benefit maintenance, provider contract and regulatory implementation. Provide assistance to other departments in these areas.
  • Establish and maintain excellent health plan, provider and member relations.
  • Facilitate business operations between PCN and external insurance companies to meet their requirements.
  • Represent PCN at operations meetings with insurance companies and software vendors.
  • Coordinate the development of Board metrics and dashboard reporting.
  • Establish short-term and long-term (annual) department goals in alignment with PCN and Polyclinic strategic goals and objectives.
  • Contribute to PCN’s effectiveness and profitability through a focus on continuous quality improvement, development of collaborative working relationships, and representation of department in overall management activities.
  • Perform other related duties as assigned to meet the needs of the organization.


  • Establish staffing structure for the functional responsibilities associated with claims services.
  • Recruit and hire for all direct reports.
  • Communicate, implement, and follow personnel policies and procedures within areas of responsibility.
  • Identify training needs of individuals and staff with mentored development of performance improvement plans as needed.
  • Establish performance expectations and administer individual job performance counseling as needed.
  • Conduct new employee and annual performance appraisals in conjunction with creation of staff development plans and annual goal setting.
  • Assure adequate staff coverage to meet business needs, to include consideration and approval of staff PTO.


  • Obtain input and feedback from stakeholders and staff in the development of the overall program budgets and collaborate with management in annual budget preparation.
  • Meet or exceed budgetary and financial goals.




    • A minimum of college Bachelor’s degree


    • Minimum requirement of over 5 years proven supervisory/management experience in Claims Operations – Process Improvement / Analysis / Automation.
    • Experience with managed care/HMO claims processing standards in an IPA, hospital, MSO, or health plan setting
    • Experience with alternative staffing models, e.g. telecommuting
    • Working knowledge of various provider reimbursement methodologies, Medicare (CMS) regulations, Coordination of Benefits, health plan division of financial responsibility (DOFR), and DMHC regulations.
    • Working knowledge of PC business applications (MS Word, Excel, PowerPoint, Access, MS Project).


    • Functional knowledge of the EZ-CAP claims administration platform and related systems and some experience with an electronic medical record
    • Working knowledge of claims processing related to Medicare statutes and regulations as directed by CMS, health plans, and other governing entities.
    • Demonstrated project management experience especially in the implementation of a new product line.
    • Strong analytical and claims processing knowledge required.
    • Ability to comprehend and interpret provider contracts, regulatory payment methodologies, etc.
    • Comprehensive mathematical ability to compute rate, ratio and percentages.
    • Ability to apply common sense and understanding to carry out instructions and respond to questions and requests from external and internal customers.
    • Strong knowledge of all claim types, methodologies and transaction types.
    • Strong organizational skills. Ability to keep track of multiple tasks and projects and prioritize work according to business needs and goals.
    • Strong analytical and problem solving skills.
    • Ability to meet all performance standards of the Polyclinic.
    • Must be able to develop and maintain effective working relationships with director, other managers, supervisors, and other team members.