What are the responsibilities and job description for the Claims Product Manager position at nirvanaHealth | RxAdvance?
Claims Product Manager
Company Overview:
Join us in our mission to transform healthcare! nirvanaHealth (under RxAdvance Corp.) is committed to bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life. Success radiates across all levels of our organization, driven by competitive benefits and a strong focus on employee wellness, we aim to support all aspects of employee growth.
Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare.
Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life-long learners and growers, and have an entrepreneurial and positive mindset.
Job Summary:
As the Claims Product Manager, you will be responsible for reviewing, analyzing, and processing Medicare/payer claims while partnering closely with the Product and Technology teams to support the development, configuration, and optimization of claims systems and workflows. This role ensures accuracy, compliance, and continuous improvement of claims processes through both operational execution and system enhancements.
Job Responsibilities (but not limited to):
- Partner with Product and Technology teams to translate business and claims requirements into system configurations and enhancements.
- Support the design, testing, and implementation of claims processing workflows, edits, and configuration updates.
- Provide subject matter expertise to inform product development and system optimization.
- Collaborate cross-functionally with Product, IT, and stakeholders on claims-related initiatives and implementations.
- Review and process Medicare claims accurately and efficiently using electronic claims processing systems.
- Verify patient eligibility, coverage, and benefits to determine claims validity.
- Analyze claims for accuracy, completeness, and compliance with coding and billing guidelines.
- Identify discrepancies, errors, or missing information and take appropriate corrective action including recommending system or process improvements.
- Review Codes (CPT, ICD-10, HCPCS) assigned to procedures, diagnoses, and services to ensure proper coding compliance and accuracy.
- Adjudicate claims by applying appropriate payment methodologies, fee schedules, and contractual agreements.
- Determine claim reimbursement amounts based on coverage, policy terms, and provider contracts.
- Determine proper adjudication of primary and secondary payer claims based on member eligibility.
- Investigate and resolve claim discrepancies, denials, and appeals.
- Identify trends, patterns, and opportunities for process and system enhancements in collaboration with Product teams
- Generate reports and analyze claims data to monitor key performance indicators (KPIs), identifying trends, and track claims processing metrics and supporting product decisions and system improvements.
Education and/or Training:
- High School Diploma required.
- Bachelors Degree in Healthcare Administration, Business Administration or related field preferred.
Professional Experience:
- 4 years of experience in Medicare claims processing or medical billing.
- Familiarity with healthcare regulations (HIPPA, CMS guidelines, etc.) and industry standards.
- Proficiency in using electronic claims processing software.
- Ability to prioritize tasks, meet deadlines, and work effectively in a fast-paced environment.
- Effective communication and interpersonal skills, with the ability to interact professionally with stakeholders at all levels.
Licenses/Certifications:
- Certification in medical coding (CPC, CCS) preferred.