Claims Manager - Hybrid - 138610

The Managed Care Claims Manager is responsible for the overall leadership, strategic oversight, and operational performance of the claims adjudication process within the managed care division. This position ensures that claims and encounters are processed accurately, efficiently, and in full compliance with regulatory, contractual, and industry standards. The Manager oversees claim adjudication workflows, monitors operational trends, and implements process improvements to optimize quality, timeliness, and regulatory adherence. This position is also responsible for maintaining readiness for health plan audits, overseeing the team that responds to data requests and implementing audit-driven improvements as well as overseeing encounter submission and rejection resubmission of encounters to health plans.

• Nine (9) years of related experience in medical claims processing, claim adjudication, encounter reporting, claims operations management, OR a Bachelor's degree in a related field plus five (5) years of related experience. Related experience includes supervisory or leadership experience in a healthcare claims environment (health plan, provider group, IPA, MSO, TPA, or managed care organization).

• Solid knowledge of the principles, concepts, systems, processes, quality improvement plans, and best practices needed for effective and successful operations in managed care contacting.

• Ability train and guide employees on techniques.

• Knowledge of medical center, HR and UC policies and processes. Solid knowledge of applicable federal, state and local laws and regulations.

• Demonstrated skills in employee supervision and HR administration. Leadership skills to motivate and inspire staff to improve Managed Care services.

• Demonstrated ability to prioritize effectively to meet deadlines in a complex, challenging environment.

• Solid organizational and customer service skills to structure unit operations and lead assigned staff in an efficient and effective manner.

• Interpersonal skills to work collaboratively, coordinate and integrate with others throughout the organization. Maintains cooperative working relationships with professional and administrative staff, peers, multidisciplinary team members, management, and external managed care representatives. Ability to positively influence subordinates in conflict resolution, and knowledge of when to escalate conflict intervention.

• Strong critical thinking skills, with the ability to quickly analyze and evaluate complex and difficult problems, and sensitive situations, determine appropriate level of intervention, and develop and apply effective solutions.

• Solid verbal and written communication skills to explain technical Managed Care concepts, actively listen, persuade, advise, and counsel.

• Strong computer proficiency in all relevant hardware, software, and specialty contract databases and applications used in the department. Ability to synthesize data and utilize computerized systems to produce meaningful reports on department operations, results, and performance.

• Experience working in a delegated claim processing environment.

• Experience processing claims in Epic Tapestry.

• Extensive knowledge of medical claims processing across all claim types, including professional, facility/institutional, ancillary, and specialty claims.

• In depth understanding of claim adjudication methodologies, including coding principles (ICD 10, CPT, HCPCS), billing guidelines, benefit structures, coordination of benefits (COB), and Explanation of Benefits (EOB) logic.

• Strong working knowledge of state and federal claims regulations, including but not limited to: CMS Medicare Advantage guidelines, Commercial plan claims requirements, Timely filing laws,Interest/penalty rules, Clean claim standards, HIPAA transaction standards (837/835).

• Experience overseeing claims appeals, disputes, adjustments, and reprocessing workflows.

• Knowledge of encounter submissions, encounter error/rejection management, and compliance with health plan encounter reporting requirements.

• Demonstrated ability to lead claims teams, including training, performance management, quality monitoring, and workflow oversight.

• Strong competency in evaluating operational trends, identifying root causes, and implementing process improvements based on quality, timeliness, accuracy, and audit findings.

• Experience ensuring audit readiness and responding to data requests from health plans, regulatory agencies, or internal compliance departments.

• Strong analytical and critical thinking abilities to interpret complex claim rules, resolve escalated claim issues, and make operational decisions.

• Ability to synthesize data, run claim related reports, and use claims processing systems and analytics tools to monitor team performance and operational results.

• Excellent written and verbal communication skills to explain claims logic, regulatory requirements, and process guidance to staff and stakeholders.

• Ability to work collaboratively with internal departments (billing/rev cycle, provider relations, UM, IS) and external partners such as health plans and providers.

• Skilled in conflict management and knowing when to escalate complex personnel or operational issues.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.