Senior Claims Manager

Senior Claims Manager at Innovent Global

Industry: Health Insurance Policies & Benefits

Location: Clearwater, FL (In-Office)

Salary: $120,000–$130,000, based on experience

Schedule: Full-Time, Monday–Friday

About the Role: A leading Third-Party Administrator (TPA) is seeking an experienced Senior Claims Manager to provide high-level leadership and strategic oversight for a fast-paced, high-volume Claims Department. This role ensures operational excellence, regulatory compliance, and exceptional service delivery across all health insurance claims functions for insurance companies, employers, and members.

The ideal candidate is a solutions-driven leader with deep TPA experience, strong operational expertise, and a proven ability to manage teams, improve processes, and influence client satisfaction.

• Serve as a senior member of the management team, supporting organizational strategy and operational performance.
• Lead and mentor Claims Managers, Supervisors, and senior staff to ensure alignment with departmental goals.
• Develop and implement strategies for performance improvement, staffing, budgeting, and workflow efficiency.
• Promote a culture of accountability, transparency, and service excellence.
• Participate in hiring decisions, succession planning, and professional development initiatives.
• Manage relationships with PPO networks, reference-based pricing partners, clearinghouses, cost-containment vendors, and claims fulfillment partners.
• Assist with escalated client concerns and key account communication.
• Support RFP responses, proposals, client presentations, and process/product improvement initiatives.

• Oversee end-to-end claims processes including receipt, re-pricing, adjudication, auditing, approvals, and payment review.
• Support automation initiatives such as electronic claims receipt, auto-adjudication, and workflow optimization.
• Ensure compliance with medical necessity reviews, pre-existing condition policies, reasonable charge determinations, and third-party liability protocols.
• Maintain documentation, SOPs, training programs, and continuous compliance readiness.

• Collaborate with Quality Management to set accuracy benchmarks, audit practices, and authority levels.
• Use audit results, KPIs, and operational data to drive continuous improvement.
• Review high-dollar or complex claims prior to payment.
• Monitor performance metrics such as SLAs, cost per claim, client satisfaction, and audit scores.

• Budget & Resource Management: Adherence to departmental budgets and cost targets.
• Service Excellence: Meet or exceed SLA performance and maintain a satisfaction rating of 4/5 or higher.
• Quality & Accuracy: Achieve internal audit standards consistently.
• Team Leadership: Foster high engagement, strong retention, and clear professional development.

Required:

• 7–10+ years of leadership experience in health insurance claims operations, with TPA experience required.
• Deep knowledge of claims processes, systems, workflows, and vendor relationships.
• Strong leadership, communication, and team development skills.
• Strategic thinker with excellent organizational and analytical abilities.

Preferred:

• Bachelor’s degree in Business, Health Administration, or related field.
• Experience with claims automation, auto-adjudication, and vendor management.

• In-office role with significant computer use, communication, and data entry.
• Occasional lifting (up to 30 lbs) and extended periods of sitting may be needed.
• HSA and FSA options
• Company-paid life & disability insurance
• Generous PTO and paid holidays
• 401(k) with company match (eligibility-based)
• Employee Assistance Program
• Frequent appreciation events & recognition programs
• Clear opportunities for advancement
• Collaborative and high-retention workplace
• Convenient Clearwater office location

If you are a results-oriented leader with extensive TPA claims experience and a passion for operational excellence, we encourage you to apply.