SummaryThe
Claims Manager is responsible for planning, developing, and managing the administration of routine to moderately complex claims programs, ensuring adherence to established policies, procedures, and regulatory requirements. Oversees billing, claims processing, adjustments, and appeals, while coordinating with internal teams and third parties to resolve discrepancies and optimize collections. Leads reporting on key financial and operational metrics, supports policy and process improvements, and engages in both operational and strategic client discussions. Additionally, manages staffing functions including hiring, training, performance management, and budgeting to drive team effectiveness and departmental success. Only those in Vermont will be considered for this role.
Your role in our mission- Plans, develops and manages administration of routine to moderately complex claims programs to ensure proper claims policies, practices and procedures are adhered to.
- Manages and approves small to medium sized billing statements, claims and associated administrative activities to ensure compliance with laws, regulations, policies agreements, and contractual arrangements.
- Plans and implements procedures to adjust claims when original demographic, sponsor or charge information is in error; monitors and controls resubmission of denials, rejections and appeals.
- Manages, and as necessary, intercedes with third parties in unusual situations involving payment or adjustment of charges on accounts; consults with departments concerning services which affect collection of charges.
- Competency to lead and/or participate in a wide-range of claims related conversations both operational and strategic with the client
- Manages, coordinates and prepares periodic reports on department activities including productivity, cash collections, status of accounts receivable, unbilled accounts, allowances, adjustments, related functions, audits and financial reporting.
- Participates in developing and implementing policies and procedures consistent with those of the organization to ensure efficient and safe operation of the unit.
- Selects and hires employees. Trains and evaluates employees to enhance their performance, development, and work product. Addresses performance issues and makes recommendations for personnel actions. Motivates and rewards employees including providing salary increases, bonuses and promotions within allocated budgets and company guidelines.
- Prepares and recommends operating and personnel budgets for approval. Monitors spending for adherence to budget, recommends variances as necessary.
- A self-starter that motivates a team and drive results.
- Manage and carry out multiple priorities with adherence to strict deadlines.
What we're looking for- Bachelor's degree in business administration, insurance or related field preferred
- Nine or more years of claims experience in payer and/or health plan environment; Medicaid preferred, with experience working with proper claims handling, policies, and procedures
- Five or more years of leadership or supervisory experience
- Experience working with computer-based analysis tools, applicable laws, regulations and practices regarding the insurance and/or medical industry
- Multi-disciplinary level of healthcare business acumen with seeking out and implementing continuous quality improvement into existing processes
- Must be in Vermont to be considered for this position.
What you should expect in this role- This is a full-time permanent regular salaried (W-2) employee position.
- Monday through Friday work schedule (40 hours per week).
- Will work 1-2 days in Willingston, VT office while other days will be worked from home.
- Upward career advancement is possible and encouraged.
- Health (medical, dental, vision) benefits start on day 1 of employment.
- Company match 401K and other benefits available within months of starting.
- New employees are eligible to take advantage of flexible vacation policy after ninety (90) calendar days of employment. Any exception requires manager approval prior to employee's Gainwell start date.
- Company provided computer for work use.
- For all hybrid and remote positions employees' Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload. Greater speeds will of course provide better performance.
- Video cameras must be used during all interviews, as well as during the initial week of orientation if hired.
- The use of AI during interviews is prohibited.
- This position will accept applications until June 22, 2026.
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The pay range for this position is $79,000.00 - $112,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.
