Manager, Claims Reporting

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member. We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong.

Visit http://www.amidacareny.org for more information about the Amida Care culture. We are actively seeking a highly motivated, innovative and experienced individual to join our team as the Manager, Claims Reporting. Compensation will be commensurate with experience.

Position Summary

The Manager, Claims Reporting is responsible for overseeing the end-to-end encounter management process between the Health Plan and its vendors, ensuring accurate, timely, and compliant encounter submission and reconciliation. Working closely with the Director of Claims and Encounters, this role develops and maintains claims analytics, auditing, dashboards, and regulatory reporting while leading projects that support operational excellence, data integrity, and continuous process improvement.

Responsibilities

Responsible for documenting, monitoring, and analyzing the end-to-end encounter life cycle, both inbound and outbound. This work includes keen oversight of Amida Care’s TPA/Vendor Encounter Process and Vendor Encounter Submissions, being Amida Care’s primary liaison with the NYS APD/OSDS Unit. Perform root cause analysis of claims/encounters processing and submission issues; communicate with management and recommend opportunities for improvement. Research and document all encounter errors; perform encounter data reconciliation and statistical trend analysis.

Ensure the accuracy of claims processing and payments while meeting company standards of quality by auditing claims to identify process improvement opportunities. Analyzes and documents audit results by tracking and trending audit results. Create business requirements, conduct UAT testing and support implementation of changes. Write specifications for the advancement of present reports on various areas of claims inventory (denials, pends, appeals etc.). Reports will be created with collaborative efforts and geared to the specific end users.

Develop reports to evaluate volume trends, financial trends and any other outside variables which affect claim behaviors and industry KPIs (Key Performance Indicators). Support the Direct of Claims and Encounter Reporting with analytics and reporting centering on new and current reimbursement methodologies, claims reporting and general industry changes. Partner with the Manager of Reimbursement…

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