Claims Adjudication Manager

The Claims Adjudication Manager provides end-to-end operational leadership for one or more US healthcare payer claims functions. The role leads frontline leaders and cross-functional support teams, owns service delivery and client governance, and drives quality, compliance, workforce effectiveness, financial discipline, transformation, and continuous improvement.

• Lead claims adjudication delivery across multiple teams, queues, products, or lines of business, with the final organization size determined by the approved account model.
• Provide direction to Supervisors, Team Leads, SMEs, Quality Analysts, Trainers, and other operational support roles.
• Own delivery against client-defined SLAs, KPIs, quality standards, turnaround times, contractual controls, and operational commitments.
• Establish disciplined governance for inventory, backlog, aging, pends, rework, high-dollar claims, escalations, and service recovery.
• Ensure operational readiness for benefit changes, policy updates, system releases, seasonal volume, migrations, and new scope transitions.

• Serve as a senior operational contact for payer stakeholders and TCS leadership.
• Lead recurring operational reviews and contribute to monthly and quarterly business reviews using accurate performance, risk, and action-plan reporting.
• Manage executive escalations, communicate impact and containment actions, and drive sustainable resolution.
• Build effective partnerships across Client Operations, Quality, Training, Workforce Management, Technology, HR, Finance, Compliance, and Transformation teams.

• Maintain a strong control environment for claim accuracy, financial accuracy, documentation, privacy, access, and audit evidence.
• Oversee root cause analysis, corrective and preventive actions, quality calibration, and remediation of recurring defects.
• Support audit readiness and compliance with HIPAA; applicable CMS, Medicare, Medicaid, and state requirements; client policies; TCS controls; and account-specific procedures.
• Escalate material delivery, compliance, privacy, financial, and customer-impact risks through established governance channels.

• Build leadership capability through coaching, succession planning, performance management, recognition, and targeted development.
• Partner with Workforce Management and Talent Acquisition on demand forecasting, capacity, hiring, training throughput, scheduling, utilization, and retention.
• Manage controllable costs, overtime, staffing mix, productivity, and account financial commitments within delegated authority.
• Promote a culture of ethics, inclusion, accountability, customer focus, and continuous improvement.

• Identify opportunities to improve workflow, controls, first-pass accuracy, automation, straight-through processing, and digital enablement.
• Develop business cases and implementation plans with Technology, Transformation, Quality, and Client stakeholders.
• Track realized outcomes and sustain improvements through standard work, governance, and performance reporting.

• Bachelor's degree required; an advanced degree is preferred.
• Eight or more years of US healthcare payer operations experience, including substantial claims adjudication experience and at least five years in people and delivery leadership roles.
• Demonstrated experience leading multi-team healthcare operations and frontline leaders; the final span will be aligned to account size and complexity.
• Deep understanding of professional and institutional claims, benefits, eligibility, authorization, provider reimbursement, coordination of benefits, adjustments, denials, pends, appeals or payment-integrity touchpoints.
• Experience with Commercial, Medicare Advantage, Medicaid, managed care, or employer-sponsored plan operations.
• Experience with an enterprise payer claims platform such as Facets, QNXT, Health Rules, NASCO, Amisys, or an equivalent system.
• Strong client relationship management, executive communication, operational governance, financial acumen, risk management, and data-driven decision-making skills.
• Ability to work from the Cincinnati area and support client-defined business hours, including schedule flexibility during transitions, peak periods, or critical incidents.