Senior Claims Configuration Manager

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

📋 Description

• Take ownership of the auto-adjudication rate as a key operational metric.

• Gain an in-depth understanding of flags and the reasons for claims being routed to manual review.

• Assess flags for their business value, accuracy, and operational costs.

• Collaborate with Engineering to retire, refine, or automate flags, and create new ones when necessary for human review.

• Act as the primary expert in matching claims to provider contracts and contract groups.

• Identify and rectify provider contract mismatches that lead to incorrect payments.

• Work alongside Provider Operations and Network to ensure alignment between contract intent and claims processing.

• Manage the logic that generates member Explanation of Benefits (EOBs) and provider Explanation of Payments (EOPs).

• Guarantee that communications accurately reflect adjudication outcomes, member cost sharing, and reasons for denials or adjustments.

• Ensure that member-facing communications comply with CMS requirements, while provider-facing communications facilitate payment reconciliation.

• Serve as a subject matter expert on remittance outputs, including 835/ERA files and payment reconciliation.

• Assist providers, Provider Services, and Engineering in resolving remittance issues and promote root-cause solutions.

• Proactively spot errors in adjudication, matching, and communication.

• Lead root cause analysis and implement sustainable solutions in collaboration with Engineering, Claims Operations, and Network/Provider Operations.

• Establish and manage a performance measurement framework for claims logic.

• Develop audits, validation testing, KPIs, and reporting concerning payment outcomes.

• Suggest improvements in response to regulatory changes, new contract structures, and emerging technology to minimize manual work, payment errors, provider friction, and operational risks.

⛳️ Requirements

• Over 6 years of experience in business operations or operational leadership.

• Comfort with ambiguity and a readiness to delve into complex claims system logic to thoroughly understand operational processes.

• Outstanding communication skills, with the capability to articulate complex claims logic to both technical and non-technical audiences.

• Proven track record of driving significant changes and measurable operational results in fast-paced settings, demonstrating a proactive approach and focus on continuous improvement.

• Strong analytical abilities, with experience in developing and tracking KPIs, as well as working with large claims datasets to diagnose adjudication results and assess operational and financial impacts.

• Ability to thrive in a fast-paced, metrics-driven environment while managing multiple initiatives simultaneously.

• Curiosity and practical experience with AI tools, automation, or LLM-based workflows in operational contexts are highly desirable.

• Knowledge of health insurance claims processing, particularly in Medicare Advantage, including adjudication workflows, provider contracting, and regulatory compliance requirements.

• Experience collaborating with Engineering on rules-based systems, workflow design, or claims platform development.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, excluding Director and above.

• Commission eligibility for Sales positions.

• Parental leave program.

• 401K program.