Sr Manager, Claims Operations

Position Summary

The Senior Manager of Claims Operations is responsible for overseeing the intake, adjudication, and processing of medical claims in compliance with ERISA, CMS, and health plan guidelines. This leadership role ensures strategic operational excellence, fosters vendor and partner collaboration, and drives continuous process improvements. The Senior Manager will provide mentorship to a growing team of claims and appraisal staff, develop and implement policies, and ensure high levels of service delivery for stakeholders.

Key Responsibilities

 Department Leadership & Oversight

• Manage day-to-day operations of the claims department, ensuring claims are processed accurately, timely, and in compliance with regulatory requirements.
• Supervise and develop appraisal and examination staff while providing technical guidance to claims teams, producers, and account managers.
• Handle escalated, complex, or high-value claims with deep subject matter expertise, particularly in Workers’ Compensation statutes and best practices.

Strategic Operations & Compliance

• Ensure compliance with ERISA, CMS, HIPAA, state regulations, and internal health plan policies.
• Develop and enforce claims policies and procedures that align with company objectives and legal requirements.
• Partner with compliance and audit teams to prepare for internal and external reviews.

Vendor & Partner Management

• Manage relationships with third-party administrators, vendors, and technology partners to ensure service levels and operational efficiency.
• Lead vendor evaluations, contract performance monitoring, and process improvement initiatives.

Mentorship & Staff Development

• Provide mentorship, coaching, and performance evaluations to team members to foster professional growth and improve retention.
• Oversee hiring, training, and succession planning within the claims operations team.

Customer & Stakeholder Service

• Serve as a point of escalation for stakeholders, including providers, members, and internal departments.
• Proactively address inquiries and concerns, ensuring satisfaction and transparency throughout the claims lifecycle.

Data Analysis & Process Improvement

• Analyze claims data to identify trends, detect irregularities, and develop strategies to improve efficiency and reduce costs.
• Implement technology-driven solutions to improve claims accuracy, cycle times, and reporting.

Qualifications

• Education: Bachelor’s degree required in Healthcare Administration, Business Administration, Finance, or a related field; Master’s degree (MBA, MHA, or equivalent), or equivalent years of experience
• Experience: Minimum of 8–10 years of progressive experience in medical claims operations within a health plan, TPA, or managed care organization, including 5 years in a leadership/management role.
• Technical Expertise: Strong knowledge of ERISA, CMS regulations, Workers’ Compensation statutes, HIPAA, and state-specific health plan requirements. Proficiency with claims adjudication systems (e.g., EZ-CAP, Facets, QNXT, or similar).
• Skills:
  • Demonstrated ability to lead and develop high-performing teams.
  • Strong vendor and partner management experience.
  • Exceptional analytical and problem-solving abilities.
  • Excellent communication and negotiation skills.
  • Proficiency with Microsoft Office Suite, Teams, and reporting tools.
• Certifications (Preferred): Certified Claims Professional (CCP), Certified Health Insurance Executive (CHIE), or related industry certifications.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!

Join AMM and experience a workplace where your health, growth, and happiness comes first!