Claims Operations Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Process all claims efficiently and accurately, while developing and enhancing comprehensive medical claims workflows, including adjudication, pend processes, and payment procedures.

• Design an advanced inventory management system that enables transparent reporting and aligns with critical performance indicators (KPIs).

• Manage complex and high-value claims, effectively addressing escalations. Monitor issues from initial discovery through to resolution and corrective actions.

• Extract insights from data analysis to report on essential metrics, pinpoint risks, and recommend enhancements.

• Collaborate with diverse teams to recognize and implement process improvements, ensuring high-quality and timely claim processing while adhering to service level agreements.

• Uphold performance standards in conjunction with our Auditing team and internal policies to validate accurate payments, proper authorizations, and the resolution of system holds.

• Guide and mentor a high-achieving claims team made up of both Gravie employees and vendor partners, promoting accountability, teamwork, and professional development.

• Develop comprehensive training programs for new hires and ongoing development opportunities for current staff.

• Work closely with configuration, optimization, finance, pharmacy, and network partners to enhance operations. Provide claims support for new products and business initiatives to ensure seamless integration.

• Approach every decision with a member-first perspective, prioritizing their needs in all actions taken.

• Exemplify our core competencies: authenticity, curiosity, creativity, empathy, and a focus on achieving outcomes.

⛳️ Requirements

• Bachelor’s Degree or equivalent experience.

• In-depth knowledge of medical claims and an understanding of end-to-end processes.

• A minimum of 5 years of relevant experience in claims, with prior experience in managing a team or serving as a leader for an operational team.

• Strong knowledge of self-funded and level-funded health plans.

• Excellent problem-solving abilities.

• Dedication to delivering exceptional member experiences and interactions.

• Superior communication skills.

• Proven track record of achieving results through collaboration.

🏝️ Benefits

• Alternative medicine coverage.

• Flexible PTO.

• Up to 16 weeks of paid parental leave.

• Paid holidays.

• 401k program.

• Transportation perks.

• Education reimbursement.

• 2 days of paid paw-ternity leave.