Manager, Claims Operations and Integrity

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Develops and oversees the claims payment dispute resolution process, including investigation, analysis, and resolution of complex claims issues.
• Manages a team responsible for identifying, researching, and resolving payment discrepancies, denials, and underpayments.
• Collaborates with internal and external stakeholders to resolve payment disputes promptly and effectively.
• Implements strategies to reduce claim errors and payment delays.
• Oversees the day-to-day operations of the claims processing department, ensuring adherence to established procedures and timelines.
• Monitors claims processing metrics and identifies opportunities for process improvement.
• Ensures compliance with regulatory requirements related to claims processing and payment.
• Develops and implements a robust claims quality audit program to assess accuracy, completeness, and compliance of claims processing.
• Identifies trends and root causes of claim errors and develops corrective action plans.
• Monitors and reports on claims quality metrics and performance indicators.
• Identifies opportunities for claims recovery and cost savings through data analysis and process optimization.
• Develops and implements strategies to recover overpayments, prevent fraud, waste, and abuse.
• Collaborates with cross-functional teams to identify and implement affordability initiatives that impact claims costs.
• Monitors and reports on claims recovery and affordability performance metrics.
• Performs all duties inherent in a managerial role. Approves staff training, hiring, promotions, terminations, and salary actions and evaluates staff performance for direct reports. Participates in the development of and ensures adherence to department budget.
• Participates in special projects and performs other duties as assigned.

Education:

• Bachelor's Degree in healthcare administration, business, or related field required

Work Experience:

• Minimum of 5 years of experience in healthcare claims processing, payment integrity, or related field required
• Proven leadership and team management skills required
• Experience with claims adjudication systems and data analysis tools required
• Proficient PC skills, including Microsoft Office Products such as Excel, Access, Word and PowerPoint required
• Effective communication skills, both written and oral required
• Experience with health care information systems. i.e. Facets, Salesforce preferred
• Knowledge of healthcare regulations and compliance requirements preferred
• Experience in problem-solving and analytical skills required