Manager, Claims Processing

About the role

The Manager of Claims Processing will lead teams responsible for ensuring that claims are processed according to network and client Service Level Agreements and in accordance with Plan Documents, Regulatory standards, and established policies and procedures. This position is responsible for management of all claim inventories and leading teams in a fast paced, high growth environment that demands strong decision making, adaptability, and effective cross functional coordination. Additionally, this position will support strategies and enhancements that are implemented to improve the claims process and enhance member experience.

Responsibilities

• Monitor inventory, productivity, and quality reports for all books of business to ensure that all claims are handled timely and accurately
• Lead initiatives to manage/reduce inventory levels through data driven analysis, forecasting improvements, and innovative problem solving
• Oversee key networks, products, and individual client performance requirements with a focus on service excellence, performance compliance, and audit requirements
• Manage elevated authority claim reviews to ensure appropriate handling; release claims accurately and timely in conjunction with dollar authority limit set for Manager role
• Provide comprehensive support for new clients and products across all books of business
• Collaborate with internal stakeholders to resolve, address escalated client/broker issues, and streamline workflows for better efficiency and accuracy
• Attend outside audits as needed to ensure accurate reporting
• Develop and implement strategies that align with the company’s overall goals and objectives
• Attend continuing education classes as required, including but not limited to HIPAA training
• Adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto
• Lead, coach, motivate and develop; responsible for one-on-one meetings, performance appraisals, growth opportunities and attracting new talent
• Clearly communicate expectations, provide employees with the training, resources, and information needed to succeed
• Actively engage, coach, counsel and provide timely, and constructive performance feedback
• Perform other duties as assigned

Requirements

• Bachelor's degree or equivalent work experience required
• A minimum of 5 years of medical claims analysis and adjudication experience (including dental and vision claims analysis) required
• A minimum of years’ experience at a supervisor level with demonstrated leadership competencies

Skills

• Demonstrated understanding of Claims Management systems and platforms
• Strong analytical and technical claims expertise across relevant lines of business
• Proficiency with CPT, HCPCS, and ICD-10 coding
• Knowledge of Coordination of Benefits (COB) and medical terminology
• Excellent written and verbal communication skills
• Exceptional time management skills and ability to prioritize work
• Strong problem solving and conflict resolution skills and ability to handle sensitive client escalations

Position Competencies

• Accountability
• Coaching and Feedback
• Collaboration
• Customer Focus
• Decision Making
• Execution Management
• People Leadership

Physical Demands

This is a standard desk job requiring extended sitting and computer work.

Work Environment

Remote. Reliable internet service of at least 100Mbps download/25Mbps upload via cable broadband or fiber optic provider is required.