Claims Manager

About the role

The Claims Department Manager oversees the day-to-day operations of the health plan’s claims processing unit, ensuring timely and accurate adjudication of claims. This role manages a team of claims examiners and support staff, maintains compliance with regulatory and contractual obligations, and leads initiatives to improve operational efficiency. The manager also handles claim denials and appeals, collaborates with internal departments and external providers to resolve complex issues, and upholds AHF’s Core Values and Mission.

Responsibilities

• Manage, coach, and develop a team of claims examiners and department support associates.
• Monitor performance metrics and conduct regular performance evaluations.
• Foster a culture of accountability, collaboration, and continuous improvement.
• Ensure timely and accurate processing of provider claims in accordance with plan policies and regulatory requirements.
• Oversee daily inventory management to balance workloads and meet service levels.
• Monitor and manage claim denials, rework, and appeals/disputes processes.
• Ensure compliance with all regulatory requirements.
• Implement and oversee internal audits to ensure claims accuracy and identify trends or training needs.
• Collaborate with the Quality and Compliance teams to address audit findings and implement corrective actions.
• Partner with IT and vendors to ensure claims system functionality, updates, and issue resolution.
• Identify and implement process improvements to enhance efficiency and reduce errors.
• Serve as a liaison with providers to resolve claim disputes and ensure timely communication.
• Collaborate with Provider Relations, Member Services, and UM/Medical Management to address cross-functional issues.
• Generate and analyze operational reports to track productivity, turnaround times, and denial trends.
• Present findings and recommendations to leadership for strategic planning.
• Perform other related duties and special projects as assigned to support departmental and organizational goals.

Requirements

• 3-5 years of Claims Management experience preferred.