The Claims Department Manager is responsible for overseeing the day-to-day operations of the health plan's claims processing unit. This role ensures timely and accurate adjudication of claims, manages a team of claims examiners and support staff, and maintains compliance with regulatory and contractual obligations. The manager will also lead initiatives to improve operational efficiency, manage claim denials and appeals, and collaborate with internal departments and external providers to resolve complex issues.
The Claims Department Manager enhances the reputation of AHF by meeting key respobsibities as assigned by department management.
Key Responsibilities:• Team Leadership & Supervision• Manage, coach, and develop a team of claims examiners and department support associates. Monitor performance metrics and conduct regular performance evaluations. Foster a culture of accountability, collaboration, and continuous improvement.• Ensure timely and accurate processing of provider claims in accordance with plan policies and regulatory requirements Oversee daily inventory management to ensure workloads are balanced and service levels are met. Monitor and manage claim denials, rework, and appeals/disputes processes. Ensure compliance with all regulatory requirements.• Quality Assurance & Auditing• Implement and oversee internal audits to ensure claims accuracy and identify trends or training needs. Collaborate with the Quality and Compliance teams to address audit findings and implement corrective actions.• System & Process Management• Partner with IT and vendors to ensure claims system functionality, updates, and issue resolution. Identify and implement process improvements to enhance efficiency and reduce errors.• Provider & Stakeholder Relations• Serve as a liaison with providers to resolve claim disputes and ensure timely communication. Collaborate with Provider Relations, Member Services and UM/Medical Management to address cross-functional issues.• Reporting & Analytics• Generate and analyze operational reports to track productivity, turnaround times, and denial trends. Present findings and recommendations to leadership for strategic planning.• Other Duties• Perform other related duties and special projects as assigned to support departmental and organizational goals. Qualifications: 3-5 years of Claims Management experience preferred.
Benefits at AHF
AHF offers comprehensive benefits to help our employees do and be their very best! These benefits are intended to enhance employee physical, financial, spiritual and professional health.
