SummaryGainwell Technologies is seeking an experienced
Claims Suspense Manager to lead claims operations supporting California's Medi-Cal program.
In this role, you will provide operational leadership for teams responsible for researching, reviewing, and resolving suspended Medi-Cal claims. You will lead supervisors, oversee claims inventory and operational performance, and help ensure claims are processed accurately, timely, and in accordance with contractual requirements, policies, regulatory standards, and client service level agreements (SLAs).
You will also partner with clients and internal leaders to address operational challenges, improve claims accuracy, reduce appeals, and drive continuous improvement across the claims operation.
Your role in our mission- Lead and manage Claims Suspense operations, ensuring claims policies, procedures, contractual requirements, and established service levels are consistently achieved.
- Oversee claims and appeals processing activities, including inventory, quality, productivity, accuracy, turnaround times, and other key operational performance measures.
- Lead, coach, and develop supervisors while fostering a culture of accountability, collaboration, employee development, and continuous improvement.
- Monitor operational performance through KPIs and SLAs, identify trends and risks, and implement strategies to improve claims accuracy, productivity, and overall performance.
- Partner with clients, leadership, and internal stakeholders to resolve operational challenges, strengthen relationships, and deliver effective business outcomes.
- Develop and implement initiatives to improve claims processing, reduce appeal volumes, strengthen quality, and improve the overall efficiency of claims operations.
What we're looking for- Bachelor's degree or an equivalent combination of education and relevant experience; a degree in business administration, insurance, healthcare administration, or a related field is preferred.
- Nine or more years of experience in healthcare claims, claims operations, claims adjudication, insurance operations, Medicaid/Medi-Cal, or related healthcare operations.
- Five or more years of leadership or supervisory experience, including experience leading supervisors, team leads, or operational teams.
- Experience managing operational performance through KPIs, SLAs, workforce planning, reporting, budgets, client relationships, and continuous process improvement.
- Strong knowledge of healthcare claims processing, claims policies and procedures, insurance or medical terminology, and applicable regulatory requirements.
- Strong leadership, analytical, problem-solving, organizational, and communication skills with the ability to manage multiple priorities and effectively partner with clients and senior leadership.
What you should expect in this role- This is a hybrid position that will primarily work remotely, with occasional in-office requirements at our West Sacramento, CA office based on business, operational, client, or leadership needs.
- Candidates must be able to report to the West Sacramento office when required.
- You will lead a fast-paced, metrics-driven claims operation with responsibility for quality, productivity, service levels, employee performance, and operational results.
- This position requires regular collaboration with clients, business leaders, supervisors, and other internal stakeholders.
- To work effectively as a teleworker with Gainwell, employees must have a broadband internet connection with a minimum speed of 24 Mbps download and 8 Mbps upload. Higher speeds are recommended for optimal performance.
This posting is being used to build a pipeline of qualified candidates for current and future opportunities.#LI-HYBRID
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The pay range for this position is $84,600 - $120,800 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
