Position Details
About this role
The Claims Manager oversees healthcare claims and stop loss coordination, ensuring claims are processed accurately, timely, and in compliance with ERISA, HIPAA, and plan requirements. The manager leads staff, resolves complex escalated issues, manages appeals, and drives continuous improvements in efficiency, quality, workflows, and cost control.
Key Responsibilities
- Lead and manage claims staff and workload distribution
- Resolve complex escalated claims issues and serve as SME for coverage interpretation
- Oversee adjudication, research, appeals, disputes, and escalations
- Ensure compliance with ERISA, HIPAA, and plan requirements
- Analyze trends and drive continuous improvement through workflow and system changes
Technical Overview
Leads claims operations including adjudication, appeals, and escalations while ensuring correct coding and pricing logic (CPT, HCPCS, Revenue codes, ICD 9/10; COB payments; Network/Medicare/UCR). Partners with IT/vendors for system updates, UAT, and defect resolution and contributes to auto-adjudication optimization; familiarity with VBA Software is preferred.
Ideal Candidate
The ideal candidate is a senior claims leader with 5-7 years of healthcare claim processing experience, including CPT/HCPCS/Revenue codes and ICD 9/10 knowledge plus COB payments and distribution of funds. They have 2–5+ years of supervisory experience and stop loss expertise, with strong compliance focus on ERISA and HIPAA.
Must-Have Skills
Nice-to-Have Skills
Tools & Platforms
Required Skills
Hard Skills
Soft Skills
Industry & Role
Keywords for Your Resume
Deal Breakers
5-7 years of healthcare claim processing experience, Thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD 9/10), Stop loss experience including contract types and claims filing requirements, Must have 2–5+ years of supervisory/leadership experience
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