Claims Manager

Description

The Claims Manager is responsible for overseeing the daily operations, performance, and regulatory compliance of the Claims Department within the Managed Services Organization (MSO). This role provides leadership and supervision to Claims Examiners and ensures the accurate, timely, and compliant adjudication of professional and institutional claims in accordance with health plan contracts, regulatory requirements, and organizational policies.

The Claims Manager monitors claims inventory, production, and quality metrics, ensures adherence to turnaround time standards, and supports operational efficiency and compliance with federal and California regulatory requirements, including Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and Department of Health Care Services (DHCS) requirements where applicable.

This position plays a critical role in ensuring claims processing accuracy, maintaining provider satisfaction, protecting organizational financial integrity, and supporting delegated managed care operations.

Current content is embedded in the overview. The role focuses on overseeing daily operations, monitoring claims metrics, leadership of staff, and ensuring compliant adjudication of claims in line with contracts and regulations.

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

• Minimum:
  High School Diploma or equivalent.
• Preferred:
  Bachelor’s degree in Healthcare Administration, Business Administration, or related field.

Experience

• Minimum:
  At least five years of managed care claims processing experience. Two or more years of supervisory or leadership experience. Experience processing professional and institutional claims.
• Preferred:
  Experience in MSO, IPA, or delegated managed care environment. Experience with Medicare, Medi-Cal, Commercial, and managed care claims. Experience with claims systems such as EZ Cap, EPIC, or similar platforms. Experience supporting regulatory and delegation audits.

Skills, Knowledge & Abilities

• Strong knowledge of managed care claims processing and adjudication.
• Knowledge of CPT, HCPCS, ICD-10, and UB-04 claim processing standards.
• Knowledge of DMHC, CMS, DHCS, and managed care regulatory requirements.
• Strong leadership and staff supervision skills.
• Strong analytical, organizational, and problem-solving skills.
• Ability to assess workload and staffing requirements.
• Excellent written and verbal communication skills.
• Proficiency in Microsoft Office Suite, including Excel.
• Ability to manage multiple priorities in a deadline-driven environment.
• Ability to maintain confidentiality and data integrity.
• Ability to collaborate effectively with internal and external stakeholders.

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and data review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance.

Occasional lifting of materials up to approximately 10–20 pounds may be required. The position may require extended work hours or weekend work to meet operational and regulatory deadlines.