Manager, Claims Operations and Integrity

OverviewOversees the efficient and accurate processing of claims, resolution of payment disputes, and implementation of claims quality improvement initiatives. This role is critical in ensuring financial integrity, compliance with regulatory requirements, and the delivery of exceptional provider experiences.

Compensation Range:$98,200.00 - $130,800.00 Annual

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.

Qualifications

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