Senior Manager, Claims Operations

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

📋 Description

• Direct the daily operations of the claims department and manage the entire claims lifecycle from the initial submission to adjudication, payment, denial, adjustment, and final reconciliation.

• Create and uphold scalable claims workflows, policies, procedures, and internal controls.

• Track claims volumes, payment activities, outstanding claims, denials, rejections, adjustments, and exceptions.

• Detect duplicate, rejected, incorrectly processed, or unresolved claims and facilitate their resolution.

• Implement claims aging and exception-management procedures.

• Ensure claims operations adhere to contractual, client, Medicaid, and regulatory standards.

• Supervise the processing, validation, and reconciliation of 835 Electronic Remittance Advice files.

• Manage 837 healthcare claims and encounter transactions, including submission, acceptance, rejection, and reconciliation.

• Oversee Medicaid encounter reporting and reconcile encounter data with underlying claims and transportation activities.

• Collaborate with Technology and Product teams to address EDI, data, claims-processing, and systems integration challenges.

• Develop controls for claims and encounter file transmission, acceptance, and reflection in downstream systems.

• Assist with Medical Loss Ratio (MLR) reporting and analysis.

• Reconcile claims and transportation expenses with client funding, provider payments, remittance activities, and financial reporting.

• Support Finance in month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and claims-related accounting needs.

• Provide insights into claims trends and cost factors impacting client profitability and MLR performance.

• Ensure reconciliation between operational claims systems and the General Ledger.

• Manage claims-related processes that support transportation provider payments.

• Establish controls for accurate payments to transportation providers.

• Reconcile provider payments with underlying trip and claims data.

• Collaborate with Finance and Operations on provider payment processes, including RAMP or similar platforms.

• Identify and rectify payment discrepancies, duplicate payments, missing payments, and other exceptions.

• Develop and maintain claims dashboards, KPIs, and management reporting.

• Set measurable service levels and performance standards.

• Provide senior management with insights into claims performance, financial risks, operational hazards, and emerging trends.

• Evaluate claims processes for automation opportunities, enhanced controls, and greater efficiency.

• Serve as a liaison between Claims, Finance, Accounting, Operations, Product, Technology, and Compliance.

• Assist in designing and improving MediDrive's claims technology infrastructure.

• Collaborate with healthcare clients and internal stakeholders to resolve claims, encounter, reconciliation, and reporting issues.

• Support audits, client reviews, and requests for claims-related documentation.

• Contribute to building and developing the Claims team as transaction volumes and the client base expand.

⛳️ Requirements

• Bachelor's degree in healthcare administration, finance, accounting, business, information systems, or a related field, or equivalent relevant professional experience.

• 5+ years of experience in healthcare claims operations.

• Proven responsibility for high-volume claims processing, reconciliation, or payment operations.

• Strong practical experience with 835 remittance files and 837 claims/encounter transactions.

• Background in Medicaid, managed care, health plans, TPA operations, NEMT, or other healthcare claims environments.

• Experience in supporting or analyzing Medical Loss Ratio (MLR) calculations and claims cost reporting.

• Solid understanding of claims adjudication, denials, adjustments, reconciliation, and encounter reporting.

• Experience in developing claims controls, reconciliations, dashboards, KPIs, and management reporting.

• Excellent analytical skills with the capacity to identify discrepancies across large volumes of claims and payment data.

• Ability to collaborate effectively across Finance, Accounting, Operations, Product, Technology, and Compliance functions.

• Direct experience in Non-Emergency Medical Transportation (NEMT), transportation benefits, or healthcare transportation is highly preferred.

• Experience with Medicaid transportation claims and encounter reporting is strongly preferred.

• Proficiency in reconciling transportation provider payments to claims and trip-level data is strongly preferred.

• Familiarity with RAMP or similar provider/payment platforms is highly desirable.

• Experience in helping to build or scale a claims operation within a rapidly growing organization is strongly preferred.

• Proven experience working with claims technology, EDI platforms, or claims management systems is strongly preferred.

• Advanced Excel and data analysis skills are strongly preferred.

🏝️ Benefits

• Comprehensive health insurance plans.

• Generous paid time off and holiday policies.

• Opportunities for professional development and advancement.

• A collaborative and supportive work environment.