Claims Manager - Remote

Overview

The Claims Manager oversees the Claims Department, ensuring timely, accurate, and compliant processing of healthcare claims and stop loss coordination. This role provides daily leadership, technical expertise, and cross-functional collaboration while driving continuous improvements in efficiency, quality, workflows, and cost management.

In Short

• Lead, coach, train and manage claims staff; oversee workload distribution and performance.
• Resolve complex and escalated claim issues.
• Oversee adjudication, research, appeals, disputes, and escalations.
• Serve as SME for complex claims and coverage interpretation.
• Develop and execute strategies to optimize auto-adjudication.
• Ensure compliance with ERISA, HIPAA, and other applicable rules.
• Review, analyze and process appeals in accordance with guidelines.
• Analyze trends, errors, and system issues; identify root causes.
• Participate in system updates, UAT, and defect resolution.
• Work with providers, members, and internal teams to resolve issues.

Requirements

• Bachelor’s degree preferred; associate degree or equivalent experience accepted.
• 5-7 years of healthcare claim processing experience required.
• Understanding of claims pricing (Network, Medicare, UCR, etc.).
• Stop loss experience including understanding of contract types.
• 2–5+ years of supervisory/leadership experience.
• Familiarity with VBA Software claims systems strongly preferred.
• Strong analytical, communication, and problem-solving skills.

Benefits

• Supportive, innovative, collaborative, and caring culture.
• Opportunity to change the way healthcare is financed and delivered.
• Engagement in continuous improvement initiatives.
• Collaboration with internal and external stakeholders.
• Professional development and training opportunities.