Claims Operations Manager

💼 Exempt | Leadership Role

💰 $110,000 annually

We are seeking an experienced Claims Manager to lead and oversee a high-performing claims operation within a Third-Party Administrator (TPA) environment. This role is responsible for operational strategy, quality, automation, vendor management, and team leadership across all aspects of claims administration.

The Claims Manager plays a critical role in ensuring claims are reviewed, controlled, and adjudicated accurately and timely under established service level agreements. This includes strict adherence to written procedures, cost controls, and client-specific coverage requirements, while continuously improving efficiency, quality, and automation within the claims process.

Claims Operations & Strategy

• Lead claims department strategy, planning, staffing projections, budgeting, and quality improvement initiatives
• Establish and monitor operational controls related to claims cost management, including:
• Pre‑existing condition reviews
• Medical necessity determinations
• Reasonable charge enforcement
• Third‑party liability recovery
• Oversee claims processing technology, including plan building and benefit category updates aligned with medical coding and services
• Review and approve higher‑dollar claims prior to payment

Automation, Reporting & Performance

• Develop and implement strategies to increase automation, including electronic claims receipt and auto‑adjudication
• Ensure daily reporting accurately reflects all claim statuses (clearinghouse intake, repricing, examiner queues, audits, approvals)
• Establish production standards for Claims Examiners and monitor performance with department leadership

Quality, Audits & Training

• Develop, maintain, and refine policies and procedures to ensure consistency and improve quality
• Partner with Quality leadership to implement accuracy standards and audit protocols
• Set examiner release authority levels and audit percentages based on experience and quality results
• Use audit findings to drive training programs, procedural updates, and accuracy improvements
• Oversee claims training programs, including onboarding and ongoing reinforcement training

Leadership & Department Management

• Function as a key member of the management team, using metrics to guide strategy and resource decisions
• Coordinate all activities of the Claims Department Management Team, including Supervisors and Team Leads
• Interview and make final hiring recommendations for Claims Department roles
• Build a culture focused on exceptional service, transparency, and continuous quality improvement

Client, Vendor & Cross‑Department Collaboration

• Act as a liaison for client escalations related to service issues and program questions
• Investigate and participate in responses to complaints, grievances, and appeals
• Coordinate escalations with internal departments to ensure timely and complete resolution
• Manage relationships with:
• Preferred Provider Organizations (PPOs)
• Reference‑Based Pricing vendors
• Clearinghouses, cost‑control vendors, and claims fulfillment vendors
• Participate in product development, sales processes, RFPs, and prospective client presentations when requested

• 5–7 years of management experience in health insurance or benefits claims operations
• Third‑Party Administrator (TPA) experience required
• In‑depth knowledge of automated claims adjudication systems
• Strong written and verbal communication skills
• Excellent organizational skills with a high level of attention to detail
• College degree preferred

Additional Experience (Preferred)

• Network vendor relations
• Network repricing and reference‑based pricing concepts
• Project Management or industry certifications (e.g., PMP, CEBS)

• Proficiency with MS Word, Excel, PowerPoint, Access, Outlook
• Experience with Electronic Health Records
• Familiarity with benefit administration platforms, CRM tools, project management software, and database systems

• On‑site role in Clearwater, FL
• Direct access to Protected Health Information (PHI); strict HIPAA compliance required
• Company‑issued technology required; secure and private workspace mandatory
• Office-based position with standard physical demands
• Pre‑employment drug screening required

This is a leadership opportunity for someone who thrives in operational excellence, automation, quality control, and claims strategy within a TPA environment.