Healthcare Claims Manager

Job Description

REQUIREMENTS

• Five or more years of Medicare healthcare claims processing, adjusting and/or auditing experience.
• Three or more years of supervisory experience, preferably within a healthcare claims or operational role.
• Ability to function effectively in a start-up environment. This means digging in when encountering things that aren’t well-defined, keeping a positive attitude, adapting quickly to changes and not letting perfect be the enemy of good enough.
• Advanced knowledge and experience in processing Medicare claims, particularly in a manual and/or audit environment. This means deep and proven experience using Medicare’s medical policy (NCD, LCD and Billing and Coding Articles) documentation, reimbursement methodologies and fee schedules, claims processing manuals, benefit policy manuals and other online resources.
• Advanced knowledge of healthcare industry practice and regulations, including HIPAA, Medicare and Medicare Advantage guidelines.
• Strong computer skills, including advanced proficiency in Microsoft Office Suite/Google Workspace, particularly Excel/Sheets.
• Strong problem-solving skills to identify root causes of discrepancies and propose solutions.
• Exceptional attention to detail coupled with deep organizational and analytic skills.
• Ability to develop and lead a team with patience, honesty and integrity.

RESPONSIBILITIES

• Lead and supervise the accurate, timely and compliant processing of the claims inventory across the entire claims lifecycle, from intake through resolution, plus audits, reopenings and appeals.
• Develop and implement metrics/KPIs, operational policies and desk-level policies/procedures and job aids to increase accuracy and efficiency. Develop and monitor operational metrics, dashboards and reporting to provide visibility into performance and emerging trends at the team and individual levels.
• Train, mentor and supervise the claims team resources. Document and provide feedback via 1:1 meetings, team meetings, annual performance reviews and performance improvement plans.
• Collaborate with internal teams to identify day-to-day risks, dependencies and opportunities for improvement. Facilitate collaborative discussion and coordination around operational issues and escalations.
• Participate in operational reviews and planning discussions to inform strategic planning, growth initiatives and scalability efforts. Ensure operational readiness for product/client/market market expansions.
• Communicate clearly and professionally with all internal and external constituents, fostering strong, trust-based working relationships.
• Promote proactive identification, mitigation and reporting of claims-related compliance and regulatory risks. Partner with compliance, quality, legal, finance and other stakeholders to ensure policies, procedures and controls align with CMS/Medicare Advantage program and state DOI standards.
• Support audit readiness and coordination for CMS program audits, state DOI audits and internal reviews.
• Stay updated on industry regulations, coding updates and payer policies to ensure ongoing compliance and best practices.

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