Senior Manager, Claims Operations

About the role

The Senior Manager, Claims Operations will have primary responsibility for overseeing MediDrive's end-to-end claims operations, including claims submission, adjudication, reconciliation, encounter reporting, remittance processing, provider payment support, and claims-related financial reporting. This individual will work closely with Operations, Finance, Accounting, Product, Technology, and our healthcare clients to ensure claims are processed accurately, reconciled completely, and reported appropriately. A critical component of this position will be the ability to understand and manage 835 remittance files, 837 claims/encounter transactions, Medicaid encounter reporting, Medical Loss Ratio (MLR) reporting, and transportation-related claims and provider payments. This is a hands-on leadership role. The successful candidate will not only manage existing claims processes but will also identify gaps, develop solutions, establish controls and KPIs, and help create a scalable claims operating model as MediDrive continues to grow.

Responsibilities

• Claims Operations & Management
  • Lead the day-to-day operation of the claims function and oversee the complete claims lifecycle from initial submission through adjudication, payment, denial, adjustment, and final reconciliation.
  • Develop and maintain scalable claims workflows, policies, procedures, and internal controls.
  • Monitor claims volumes, payment activity, outstanding claims, denials, rejections, adjustments, and exceptions.
  • Identify duplicate, rejected, incorrectly processed, or unresolved claims and drive issues through resolution.
  • Establish claims aging and exception-management processes to ensure outstanding items are identified and resolved timely.
  • Ensure claims operations comply with applicable contractual, client, Medicaid, and regulatory requirements.
• 835 / 837 & Encounter Management
  • Oversee the processing, validation, and reconciliation of 835 Electronic Remittance Advice (ERA) files.
  • Manage and understand 837 healthcare claims and encounter transactions, including submission, acceptance, rejection, and reconciliation.
  • Oversee Medicaid encounter reporting and ensure submitted encounter data is complete, accurate, and reconciled to underlying claims and transportation activity.
  • Work closely with Technology and Product teams to identify and resolve EDI, data, claims-processing, and system integration issues.
  • Develop controls to ensure claims and encounter files are successfully transmitted, accepted, and appropriately reflected in downstream financial and operational systems.
• Medical Loss Ratio (MLR) & Financial Reconciliation
  • Partner with Finance and Accounting to support accurate and timely Medical Loss Ratio (MLR) reporting and analysis.
  • Reconcile claims and transportation expenses to client funding, provider payments, remittance activity, and financial reporting.
  • Assist Finance with month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and other claims-related accounting requirements.
  • Provide visibility into claims trends and cost drivers that may impact client profitability and MLR performance.
  • Ensure appropriate reconciliation between operational claims systems and the General Ledger.
• Transportation Provider Payments
  • Oversee claims-related processes supporting payments to transportation providers.
  • Develop controls to ensure transportation providers are paid accurately and only for properly validated and approved transportation services.
  • Reconcile provider payments to underlying trip and claims data.
  • Partner with Finance and Operations on provider payment processes, including payments made through RAMP or similar payment platforms.
  • Identify payment discrepancies, duplicate payments, missing payments, and other exceptions and ensure timely resolution.
• Reporting, Analytics & Controls
  • Develop and maintain claims dashboards, KPIs, and management reporting, including:
    • Claims submitted, accepted, rejected, and paid
    • Claims aging
    • Denials and rejection rates
    • Payment turnaround times
    • Outstanding and unresolved claims
    • Encounter submission and