Claims Manager, Medicare Advantage Plan (Flexible-Hybrid)

Description Play a vital role on our Claims leadership team, you will manage a team of claim examiners, auditors, and support staff toward operational excellence. The Claims Manager of the Medicare Advantage Plan will: Implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments. Foster a positive, high-performing team culture focused on quality and exceptional customer service Identify opportunities to enhance workflows, resolve complex claim issues, and develop practical standard operating procedures Empower the team to navigate challenging scenarios with confidence and consistency Salary Range: $98,200 - $214,600/annually Note: This position is flexible-hybrid.

Qualifications We’re seeking a self-motivated, service-driven leader with: Required: Bachelor’s degree in business, health care or a related field and/or equivalent work experience Five or more years of claims operations experience in a Medicare Advantage or related environment Three or more years of managing personnel in a claims processing environment In-depth knowledge of physician and facility billing practices, CPT coding initiatives, ICD-10 coding standards, and revenue/HCPCS coding Understanding of provider network/IPA arrangements and reimbursement methodologies, etc.

Knowledge of standard electronic and paper claim formats Familiarity with AMA and Centers for Medicare and Medicaid Services coding guidelines Computer proficiency with Microsoft Office Suite and data visualization tools Knowledge of HIPAA, DMHC, AB1455, and CMS reporting requirements Background with claims editing software (e.g., Optum CES, Web Strat, McKesson, etc.) Experience in implementing and managing Prospective Payment System vendor application (Optum PPS, MicroDyn, 3M, etc.).

(preferred) Expertise with one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXT Excellent problem identification, resolution, and analytical abilities Strong communication, interpersonal, and analytical skills Ability to develop, implement, and evaluate methods/systems to improve efficiency Ability to lead and facilitate cross-functional workgroups Proficiency in achieving compliance with regulatory requirements Ability to travel/attend off-site meetings and conferences Preferred: Certified Professional Biller (CPB) Certified Revenue Cycle Representative (CRCR)