Claims Adjudication Manager

Role Overview

• Provide day-to-day operational leadership for the Philippines-based adjudication team (examiners, auditors, and team leads), working across time zones to direct priorities and remove blockers.
• Serve as the hands-on claims SME for the campaign — personally adjudicating complex or escalated claims and modeling correct handling for the team.
• Drive accuracy, productivity, quality, and service-level goals; translate client requirements into clear, executable operating procedures.
• Partner with the offshore manager and team leads to strengthen communication, information flow, and consistency of execution.
• Act as the senior operational single point of contact (SPOC) for the client, consolidating guidance from multiple client stakeholders into one consistent set of directives for the delivery team.
• Lead client working sessions, escalations, and operational updates with confidence and credibility; provide clear written and verbal updates on performance, quality, and improvement actions.
• Manage frequently changing client requirements — capturing, sequencing, and operationalizing new directives without disrupting production.
• Own the quality program: reduce repeat errors, identify root causes, and close coaching gaps through targeted, SME-led feedback.
• Align coaching responsibilities with subject-matter expertise; design and lead calibration sessions between examiners and auditors.
• Oversee validation of production reporting; partner with the business analyst and client to resolve reporting discrepancies (e.g., over
• or under-counting) and establish a trusted tracking methodology.
• Use data to identify capacity, monitor service levels, and demonstrate measurable improvement to the client.
• Establish and maintain a centralized documentation and knowledge-management process for client directives, reducing reliance on individual knowledge.
• Partner with HR and recruiting to accelerate hiring, rebuild the candidate pipeline, and stabilize staffing levels.

Requirements

• 6+ years of U.S. healthcare claims adjudication experience, with hands-on expertise in BOTH hospital/facility (UB-04) and professional (CMS-1500/HCFA) claims.
• 3+ years leading claims teams (managing 30–40+ examiners/auditors, directly or through team leads), ideally including offshore or BPO/shared-services teams.
• Demonstrated ability to serve as a client-facing operational leader — running working sessions, owning escalations, and building client trust.
• Strong command of claims workflows, medical terminology, coding concepts, benefits, and payer/provider processes.
• Proven track record managing productivity, quality, service levels, and team performance in a metrics-driven environment.
• Experience coaching examiners and reducing error rates through structured quality and calibration programs.
• Excellent written and verbal communication; able to work effectively across cultures and time zones.
• Strong analytical and problem-solving skills, including working with production and quality data.

Benefits

• Remote work
• Flexible schedules
• Professional development opportunities