Manager, Claims Operations - Remote

Minimum 3 - 5 years’ experience in Management of a claim operations. Demonstrated skill in managing change and in team building Advanced knowledge of claims processing including deep knowledge of claims data analysis, and the setting, tracking and reporting on performance metrics. Proficient with Microsoft applications, Excel, Word, Access and Power Point. Experience with HMO Medical insurance claims with in-depth understanding of federal and state regulations. Experience with EDI transactions. Demonstrated skill in problem solving, exercising initiative, and decision-making within scope of role. Thorough understanding of claims processing compliance requirements. Ability to meet deadlines and prioritize tasks and assign work daily to the staff. Demonstrated project management experience. Ability to work independently with minimal supervision. Exceptional judgement in escalating concerns to next level leadership. Exceptional written, visual and verbal communication is necessary to lead a team and convey clear instruction. Change management skills are necessary in order to engage a team as we grow. Continuous improvement and a growth mindset are required. Claim coding experience, coding edits experience. CPT and ICD coding knowledge and medical terminology

Responsible for the day-to-day management of the Claim Operations team. Maintains and improves claims processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans. Assessing and assigning workflow, coaching, counseling. Use reporting data analytics to track KPIs and report to leadership on a daily, weekly, monthly basis. Monitor individual Analysts quality and production measures, conducting staff performance conversations, monthly 1:1’s with individual staff to review their concerns, give feedback, mentor goals and career progression. Responsible for writing and maintaining desktop procedures for claims processing functions. Identify areas within the claims workflow and system tools where the processes can be improved/enhanced, analyzing current workflows, designing and implementing changes to streamline operations and monitor the impact of those changes to ensure increased efficiency and production. Leveraging technological advantages and incorporating new workflows to scale the business. Responsible for the distribution and completion of assigned JIRA tickets relating to claims inquiries or adjustments requests. Complete first round of claims processing reviews on client reporting requirements prior to sending for their approval. Coordinate operational workflows and other internal functions alongside departments and managers. Participate in the Monthly Policy and Procedure committee meetings, complete review of policies to approve or suggestions for updates. Conduct at minimum monthly team meetings, and attend operational meetings as requested.