Claims Manager, Medicare Advantage Plan

Role Overview

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.

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

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

Required:

• 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)