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Department:  Business Services
Status:  Full Time
Shift:  1st

The Manager of Claims Operations is responsible for overseeing the core functions of the Claims department including new claims processing, provider dispute resolution, inventory management, mailroom, provider claims customer service, auditing, claim compliance, and revenue recovery.  The manager will lead activities related to system configuration and testing of provider and payor contracts, benefits, fee schedules, and claims adjudication.  The manager will be responsible for team development ensuring key performance metrics on productivity, accuracy, auto-adjudication, and compliance are met.


Essential Functions:

  • Ensure compliance with regulatory guidelines with effective management of claims and provider disputes.
  • Maintain financial and processing accuracy of claims processed through pre-payment and post-payment audits.
  • Primary resource on claims adjudication for configuration of provider contracts, plan contracts, fee schedules, and benefits.
  • Oversee claims mailroom and EDI claims submission partnering closely with Claims clearinghouse and OCR vendor to ensure integrity of paper claims and EDI claims.
  • Lead the customer service team responsible for resolving provider claim issues and inquiries providing the highest standards of customer service and maintaining metrics on first-call resolution, abandonment rate, provider satisfaction, and call duration.
  • Provide feedback, trending, and root-cause-resolution of claims issues by partnering with key internal partners (managed care contracting, IT, medical management), providers, vendors, and leadership team ensuring claims are billed and processed timely and accurately.
  • Facilitates training and team development to enhance the knowledge and skills of the team.
  • Lead and coordinate health plan and regulatory audits including recurring reporting requirements (MTRs, PDRs, ODAG, etc.).
  • Oversee revenue recovery functions including voluntary and involuntary refunds, health plan capitation deductions, retro eligibility terminations, etc.
  • Perform other duties as assigned.


Education, Training and Experience



  • Bachelor’s degree in business/healthcare administration OR four (4) years of experience in a directly related field. 
  • Five (5) years of experience in medical claims management, managing managed care staff, working knowledge of claims processing, configuration, extensive knowledge of regulatory guidelines in managed care (CMS, DMHC, DHS), strong knowledge of professional and institutional claims processing procedures.



  • Familiarity with Epic Tapestry managed care processing system


Skills or Other Qualifications



  • Demonstrated leadership ability, collaborative, team-oriented approach to decision-making, ability to perform within a metrics and data-driven healthcare delivery system, strong interpersonal, verbal, and written communication skills, strong organization skills.


Position Reports to:  Director, Claims


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