Claims Manager – Management Ancillary Support

Role Overview

• Ensure claims, appeals, and adjustments are processed accurately and in accordance with benefit plans, pricing agreements, authorizations, and regulatory requirements, intervening as needed to resolve issues and escalations.
• Oversee and manage claim inventory against established service-level agreements (SLAs), setting priorities for team members.
• Direct, coach, and develop staff, ensuring proper application of client benefit plans and achievement of quality and production standards; establish and monitor performance plans for team members falling below expectations.
• Establish clear accountability for training and onboarding outcomes, ensuring skill development is treated as essential to core operations.
• Lead the development and refinement of operational and quality KPIs across CMAS functions, with particular focus on day-to-day performance, appeals timeliness, and regulatory compliance.
• Review, analyze, and report on operational performance, including claim inventory, production volumes, turnaround lag, and quality metrics, and communicate trends and risks to department leadership.
• Develop and execute work plans to reduce claim inventory and improve service performance, including oversight of overtime usage to ensure cost effectiveness.
• Identify and drive process improvement opportunities, including workflow standardization, automation, and AI-enabled enhancements, to improve efficiency, quality, and turnaround times.
• Oversee the development and enforcement of policies and procedures to ensure claim standards are administered consistently; monitor team compliance and address gaps.
• Set team goals aligned with departmental and organizational priorities, providing ongoing feedback and formal performance evaluations to support individual growth and accountability.
• Maintain accountability for team morale and engagement, fostering collaboration by involving staff in problem-solving and solution design.
• Serve as the CMAS liaison on projects and initiatives, including claims testing and support for system implementations or upgrades.
• Partner cross-functionally to support client issue resolution and implementation efforts, ensuring CMAS considerations are incorporated into broader claims workflows.
• Act as a point of contact as needed for clients, vendors, or providers requiring CMAS relationship ownership.
• Perform other duties as deemed essential and necessary.

Requirements

• Bachelor’s degree or equivalent work experience required.
• 5+ years of experience in healthcare claims administration; self-funded and/or TPA experience strongly preferred.
• Demonstrated experience managing teams involved in claims audit, appeals, recovery, quality, or escalations.
• Strong understanding of benefit administration, claims adjudication, and regulatory requirements.
• Experience managing operational metrics, quality programs, and service levels in a regulated environment.
• Prior experience with highly automated and integrated claims adjudication systems (e.g., Javelina, Health Rules Payer, or similar).
• Strong communication, organizational, analytical, and problem-solving skills.
• Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint.

Benefits

• Offers Equity
• Offers Bonus