Claims Manager


Miami, FL

Industry: Managed Care & Health Insurance


5 - 7 years

Posted 267 days ago

  by    Aubry Woff

This job is no longer available.

Claims Manager

Reaction Search International is a leading retained global executive search firm. With offices in 42 marketplaces throughout the United States, RSI works with a wide variety of companies, from Fortune 500 down to investment-backed start-ups.


Our client is a leading company providing group employee health benefit plans, including medical, dental, life, and disability. They have a high-priority need to recruit a Claims Manager to oversee the claims department, ensuring claims are processed in accordance with turnaround times, quality, and production standards. This position reports to the Director of Operations.

Location: Caribbean Islands

Essential Duties and Responsibilities:

Duties & responsibilities include, but are not limited to:

  • Oversee work flow of the Claims Department.
  • Monitor claims and auditing turnaround times to ensure objectives are met.
  • Communicate daily inventory to the Director of Operations.
  • Confirm all industry reference material is updated accordingly.
  • Handle overpayments and follow up requests on a timely basis.
  • Report pended claims exceeding $25K.
  • Communicate staffing issues or concerns to the Director of Operations.
  • Maintain proper employee documentation.
  • Review daily mail log to identify high dollar claims meeting the external medical review criteria and handle accordingly, while notifying proper management.
  • Notifies Overseas Network Provider of claims not returned from re-pricing.
  • Identify and establish processes and procedures to ensure efficiency and consistency throughout the Claims Department.
  • Set goals and objectives for all Claims Department and individual employees.
  • Participate in recruitment process and contribute to decision making process.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

  • Bachelor?s degreerequired.
  • Certification or professional qualification in health insurance, or significant progress towards a relevant professional qualification is preferred.
  • 5 -10+ years of medical claims processing experience and knowledge of both U.S. Claims, and an understanding of various fee schedules applicable to the local market.
  • 5 -10+ years at a supervisory level in a medical claims operation.
  • Experience working with U.S. healthcare system and experience of US claims processing, provider and network discounts and negotiating contracts with independent service providers.
  • Thorough understanding of group health benefit plans including medical, dental, life, and disability.
  • Strong knowledge of ICD-9 & ICD-10, CPT, ADA, ODA coding and medical terminology.
  • Superior communications and organizational skills, and a service-oriented approach.
  • Proven ability to negotiate with external and internal clients and work under pressure.


$100K - $140K