Claims Operations Manager

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

📋 Description

• Supervise claims production and vendor management for the Medicare Advantage line of business.

• Develop, implement, and enhance internal controls along with departmental policies and procedures.

• Stay informed about government regulations pertaining to claims payments and recognized claims processing standards.

• Investigate and address claims inquiries from members, providers, networks, and government agencies.

• Ensure quality control measures are in place and analyze the root causes of discrepancies in claim payments.

• Guarantee that claim support services meet provider satisfaction and respond promptly to disputes and appeals.

• Collaborate with the Core Configuration team and vendors on claims systems.

• Coordinate the implementation and maintenance of EDI related to claims submissions and processing statuses.

• Ensure precision in claims payments and remittance documentation.

• Identify trends and solutions to minimize provider disputes.

• Oversee staff work for quality and efficiency.

• Provide training, feedback, coaching, and, when necessary, disciplinary actions to staff.

• Work together with various departments to resolve issues.

• Report problems to senior leadership.

• Support Medicare operations in compliance with MA Plan contractual obligations and CMS regulations.

• Monitor daily performance and provide reports to MRx Compliance.

• Engage in operational and compliance audits.

• Assist in planning and implementing new accounts, programs, products, and services.

• Formulate short- and long-term departmental plans and contribute to corporate and strategic objectives.

• Take part in Corrective Action Plans (CAPs).

• Support Quality Improvement initiatives during quarterly audits.

⛳️ Requirements

• A minimum of four (4) years in a managerial role or higher.

• At least four (4) years of experience in Medicare claims is required.

• Experience in Medicare/DSNP/ACA Exchange operations is preferred.

• Seven (7) years of experience in health plan administration.

🏝️ Benefits

• Comprehensive health benefits package.

• Competitive salary and performance bonuses.

• Opportunities for professional development and growth.

• Supportive work environment with a focus on teamwork and collaboration.