Senior Manager, Claims

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

📋 Description

• Manage the complete claims processing operations, ensuring precision, efficiency, and compliance with service level agreements.

• Lead and mentor a team of claims professionals, supervisors, and analysts across various claims functions.

• Establish and track KPIs such as claim cycle time, denial rates, accuracy rates, and cost per claim.

• Propel continuous process improvement efforts by utilizing automation and technology to minimize manual interventions.

• Identify, evaluate, and mitigate operational risks throughout the claims lifecycle.

• Develop and maintain a claims risk register, escalation procedures, and inform business continuity plans.

• Collaborate with finance and legal teams to evaluate claims liability exposure and trends.

• Monitor indicators of fraud, waste, and abuse, coordinating investigation protocols with relevant stakeholders.

• Ensure claims operations comply with federal and state regulations, including CMS guidelines, HIPAA, and specific plan requirements.

• Oversee audit readiness efforts and act as the primary operational contact during internal and external audits.

• Keep up-to-date with regulatory changes and translate compliance requirements into updates for operational policies and procedures.

• Develop and implement compliance training programs for claims personnel.

• Collaborate with IT, legal, finance, and vendor partners to ensure that claims systems and workflows align with organizational objectives.

• Present operational performance, risk status, and compliance updates to senior leadership and other stakeholders as necessary.

• Support organizational growth initiatives such as new product lines, client implementations, acquisitions, or system migrations from a claims operations viewpoint.

• Other duties as assigned.

⛳️ Requirements

• Bachelor’s degree in Business Administration, Healthcare Administration, Finance, or a related discipline is preferred.

• 7–10 years of progressive experience in claims operations, including a minimum of 3–5 years in a leadership capacity.

• Proven experience managing cross-functional teams within a regulated industry, ideally in healthcare or insurance.

• Demonstrated success in building and implementing compliance programs in line with CMS, HIPAA, or state regulatory standards.

• Experience leading operational audits, addressing regulatory inquiries, or managing accreditation processes.

• Practical experience in implementing process automation, claims management systems, or workflow technology.

• Strong expertise in risk identification, mitigation strategies, and operational controls.

• Experience presenting to Senior and Executive leadership, Board members, or external regulatory agencies is preferred.

• Experience with Commercial, Medicare Advantage, Medicaid, or supplemental health plans is required.

• Exceptional verbal, written, and presentation skills.

• Strong problem-solving skills and data analytical capabilities.

• Excellent organizational and time management abilities.

• Proficient in MS Office (Excel, Word, PowerPoint, Access).

• Experience with a variety of automated claims processing systems; familiarity with Plexis/Orion is a plus.

• Outstanding customer service skills.

• Relevant certifications preferred: Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), Six Sigma Green or Black Belt, Associate in Claims (AIC).

🏝️ Benefits

• Competitive salary.

• Company bonus potential.

• Medical, dental, and vision insurance.

• 401(k) with matching contributions.

• Generous paid time off.

• Complimentary gym membership to over 13,000 fitness locations across the US.

• Other excellent benefits.