Manager, Claims Operations

Overview

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service.

We are proud to say that for three years, HMA has been chosen as a ‘Washington’s Best Workplaces’ by our Staff and PSBJ™. Our vision, ‘Proving What’s Possible in Healthcare,’ and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results.

What we are looking for:
We are always searching for unique people to add to our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven.

What you can expect:
You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at:

How YOU will make a Difference:

The Claims Operations Manager will oversee the end-to-end processing of healthcare claims. The manager is responsible for leading the HMA Claims Operations staff and their daily work requirements. Leveraging metrics and forecasts; they prioritize workload and resourcing to maximize operational production in partnership with vendor resources and liaisons. The manager will lead a team responsible for claims intake, pricing, adjudication, coordination of benefits and issue resolution while driving operational excellence

• Direct supervisory responsibilities:
  Manages and coaches individual contributor’s performance and quality.
• Assess and manages claims inventory:
  Tracks and manages inventory trends and proactively adjusts resource levers as needed to maximize productivity
• Manage daily operations of claims processing, ensuring accuracy, timeliness, and compliance with healthcare policies and federal guidelines
• Create daily updates for management team flagging production rates, critical issues and areas of escalation in real time
• Monitor and resolve pricing discrepancies impacting claims adjudication and provider payments.
• Lead initiatives to improve pricing workflows, automation, and system performance.
• Vendor auditing & QA:
  Leads vendor audits and manages reporting to ensure vendor quality.
• Apply subject matter expertise to the business of claims processing and operations
• Manage to vendor agreements, proactively identify and flag issues, escalate appropriately
• Develop and maintain workflows and documentation specific to claims processing.
• Train and coach staff and vendors on claims processes as needed
• Motivate talent:
  Ability to motivate and lead team members and vendors in accordance with HMA values and objectives
• Talent planning:
  Proactively review and assess talent. Continually develop and/or recruit talent to meet objectives

• Bachelor’s Degree or equivalent work experience
• Minimum 5 years’ of claims operations experience, self-funded health plan experience is a plus
• Minimum 2 years’ of people leading experience
• Experience with claims platforms such as Health Edge, Mphasis, or Facets
• Knowledge of CPT, HCPCS, ICD-10 coding, and reimbursement methodologies.
• Strong understanding of provider contract terms, fee schedules, and pricing models (e.g., DRG, APC, RBRVS).
• Proven ability to manage and develop a team of highly skilled staff
• Proven ability to manage and interact with vendors to support execution of work within the SLA’s established

The base salary range for this position in the greater Seattle area is $100,000-$123,000 and varies dependent on geography, skills, experience, education, and other job or market-related factors. Performance-based incentive bonus(es) is…