Job Description:
Play a vital role on our Claims leadership team, you will manage a team of claim examiners, auditors, and support staff toward operational excellence. The Claims Manager of the Medicare Advantage Plan will:
- Implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments.
- Foster a positive, high-performing team culture focused on quality and exceptional customer service
- Identify opportunities to enhance workflows, resolve complex claim issues, and develop practical standard operating procedures
- Empower the team to navigate challenging scenarios with confidence and consistency
Salary Range: $98,200 - $214,600/annually
Note: This position is flexible-hybrid.
Qualifications: We’re seeking a self-motivated, service-driven leader with:
Required:- Bachelor’s degree in business, health care or a related field and/or equivalent work experience
- Five or more years of claims operations experience in a Medicare Advantage or related environment
- Three or more years of managing personnel in a claims processing environment
- In-depth knowledge of physician and facility billing practices, CPT coding initiatives, ICD-10 coding standards, and revenue/HCPCS coding
Understanding of provider network/IPA arrangements and reimbursement methodologies, etc.
Knowledge of standard electronic and paper claim formats
Familiarity with AMA and Centers for Medicare and Medicaid Services coding guidelines
Computer proficiency with Microsoft Office Suite and data visualization tools
Knowledge of HIPAA, DMHC, AB1455, and CMS reporting requirements
Background with claims editing software (e.g., Optum CES, Web Strat, McKesson, etc.)Experience in implementing and managing Prospective Payment System vendor application (Optum PPS, MicroDyn, 3M, etc.). (preferred)
Expertise with one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXTExcellent problem identification, resolution, and analytical abilities
Strong communication, interpersonal, and analytical skills
Ability to develop, implement, and evaluate methods/systems to improve efficiency
Ability to lead and facilitate cross-functional workgroups
Proficiency in achieving compliance with regulatory requirements
Ability to travel/attend off-site meetings and conferences
Preferred: Certified Professional Biller (CPB)
Certified Revenue Cycle Representative (CRCR)
