Claims Manager, Medicare Advantage Plan

Onsite or Remote - Flexible Hybrid

Work Schedule:

Monday - Friday, 8:00am-5:00pm PST

Posted Date: 03/05/2026

Salary Range
: $95,400 - $208,300 Annually

Employment Type:

Duration:
Indefinite

Job #: 28705

Play a vital role on our Claims leadership team, you will manage a team of claim examiners, auditors, and support staff toward operational excellence. The Claims Manager of the Medicare Advantage Plan will:

• Implement and maintain efficient and streamlined claims adjudication processes that effectively utilize technology to automate business processes and maximize the accuracy of claims payments.
• Foster a positive, high-performing team culture focused on quality and exceptional customer service.
• Identify opportunities to enhance workflows, resolve complex claim issues, and develop practical standard operating procedures.
• Empower the team to navigate challenging scenarios with confidence and consistency.

We’re seeking a self-motivated, service-driven leader with:

• Bachelor’s degree in business, health care or a related field and/or equivalent work experience.
• Five or more years of claims operations experience in a Medicare Advantage or related environment.
• Three or more years of managing personnel in a claims processing environment.
• In-depth knowledge of physician and facility billing practices, CPT coding initiatives, ICD-10 coding standards, and revenue/HCPCS coding.
• Understanding of provider network/IPA arrangements and reimbursement methodologies, etc.
• Knowledge of standard electronic and paper claim formats.
• Familiarity with AMA and Centers for Medicare and Medicaid Services coding guidelines.
• Computer proficiency with Microsoft Office Suite and data visualization tools.
• Knowledge of HIPAA, DMHC, AB1455, and CMS reporting requirements.
• Background with claims editing software (e.g., Optum CES, Web Strat, McKesson, etc.).
• Experience in implementing and managing Prospective Payment System vendor application (Optum PPS, Micro Dyn, 3M, etc.). (preferred)
• Expertise with one or more of the following managed care transaction systems: EPIC (Tapestry Module), EZ Cap, Facets, QNXT.
• Excellent problem identification, resolution, and analytical abilities.
• Strong communication, interpersonal, and analytical skills.
• Ability to develop, implement, and evaluate methods/systems to improve efficiency.
• Ability to lead and facilitate cross-functional work groups.
• Proficiency in achieving compliance with regulatory requirements.
• Ability to travel/attend off-site meetings and conferences.

• Certified Professional Biller (CPB)
• Certified Revenue Cycle Representative (CRCR)

As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer.