Claims Adjudication Manager

U.S.-Based Operational Leader Overseeing Philippines Claims Adjudication

Work Setup: Remote

Reports To: SVP Operations

Direct Oversight: Philippines-based claims adjudication team (examiners, auditors, team leads)

Hours: Pacific Time Zone: Core overlap with Philippines business hours required; evening calls for client/offshore alignment

Role Summary

Imagenet is seeking an experienced, U.S.-based Claims Adjudication Manager to provide hands-on operational leadership for a claims adjudication account, which is delivered through our wholly owned global delivery center in the Philippines. This is a player-coach role for a seasoned claims subject-matter expert (SME) who can bridge U.S. client expectations and offshore delivery - directly strengthening quality, throughput, reporting accuracy, and client-facing credibility.

The successful candidate combines deep adjudication expertise in both hospital (facility) and professional claims with proven experience leading and developing offshore claims teams. They will serve as the senior operational point of contact for the client, set the standard for adjudication accuracy, and build the coaching, audit, and documentation infrastructure needed to deliver consistent, high-quality outcomes at scale. They will not hesitate to role up their sleeves and dive into production and quality.

Key Responsibilities

Operational Leadership (Onshore Lead for Offshore Delivery)

• Provide day-to-day operational leadership for the Philippines-based adjudication team (examiners, auditors, and team leads), working across time zones to direct priorities and remove blockers.
• Serve as the hands-on claims SME for the campaign - personally adjudicating complex or escalated claims and modeling correct handling for the team.
• Drive accuracy, productivity, quality, and service-level goals; translate client requirements into clear, executable operating procedures.
• Partner with the offshore manager and team leads to strengthen communication, information flow, and consistency of execution.

Client Engagement & Single Point of Contact

• Act as the senior operational single point of contact (SPOC) for the client, consolidating guidance from multiple client stakeholders into one consistent set of directives for the delivery team.
• Lead client working sessions, escalations, and operational updates with confidence and credibility; provide clear written and verbal updates on performance, quality, and improvement actions.
• Manage frequently changing client requirements - capturing, sequencing, and operationalizing new directives without disrupting production.

Quality, Coaching & Audit

• Own the quality program: reduce repeat errors, identify root causes, and close coaching gaps through targeted, SME-led feedback.
• Align coaching responsibilities with subject-matter expertise; design and lead calibration sessions between examiners and auditors.
• Assess auditor capability and set audit-throughput targets that balance thoroughness with release timelines.

Reporting & Production Validation

• Oversee validation of production reporting; partner with the business analyst and client to resolve reporting discrepancies (e.g., over- or under-counting) and establish a trusted tracking methodology.
• Use data to identify capacity, monitor service levels, and demonstrate measurable improvement to the client.

Documentation & Knowledge Management

• Establish and maintain a centralized documentation and knowledge-management process for client directives, reducing reliance on individual knowledge.
• Ensure source documentation is centralized and current so that AI-assisted retrieval and other enablement tools deliver reliable answers.

Workforce & Cross-Functional Collaboration

• Partner with HR and recruiting to accelerate hiring, rebuild the candidate pipeline, and stabilize staffing levels.
• Collaborate with QA, training, workforce management, infrastructure/IT (including connectivity and latency monitoring for remote staff), and client services to support execution.
• Coordinate with consultants, business analysts, and transition partners during onboarding and ramp activities.

Must-Have Qualifications

• 6+ years of U.S. healthcare claims adjudication experience, with hands-on expertise in BOTH hospital/facility (UB-04) and professional (CMS-1500/HCFA) claims.
• 3+ years leading claims teams (managing 30-40+ examiners/auditors, directly or through team leads), ideally including offshore or BPO/shared-services teams.
• Demonstrated ability to serve as a client-facing operational leader - running working sessions, owning escalations, and building client trust.
• Strong command of claims workflows, medical terminology, coding concepts, benefits, and payer/provider processes.
• Proven track record managing productivity, quality, service levels, and team performance in a metrics-driven environment.
• Experience coaching examiners and reducing error rates through structured quality and calibration programs.
• Excellent written and verbal communication; able to work effectively across cultures and time zones.
• Strong analytical and problem-solving skills, including working with production and quality data.

Preferred Qualifications

• Experience overseeing or supporting Philippines-based or other offshore healthcare claims operations.
• Experience supporting U.S. health plans, TPAs, healthcare BPOs, or shared-services operations.
• Exposure to payment review, denials, appeals, or related claims functions.
• Experience building documentation/SOP libraries and knowledge-management processes.
• Exposure to process improvement, automation, or digital-transformation initiatives (including AI-assisted enablement tools).
• Familiarity with claims platforms and reporting validation.

Key Competencies

• Hands-on claims adjudication expertise (hospital + professional)
• Operational leadership of distributed / offshore teams
• Client and stakeholder communication; single point of contact
• Quality, coaching, and audit calibration
• Analytical thinking, reporting validation, and problem-solving
• Continuous improvement and cross-functional collaboration