DescriptionWe are currently looking for a
Claims Manager to join our growing team!
The Claims Manager provides tactical, technical leadership for claims operations with a focus on issue resolution, process improvement, auditing, and cross-functional support. This role is specialized in technical troubleshooting, claims reconciliation, batch processing, and collaboration with internal partners to ensure the smooth operation of claims workflows.
Office Location:- 2415 E Camelback Road, Suite 700, Phoenix, AZ 85016
- Remote
Responsibilities and Duties:
Responsibilities include, but are not limited to the following:
- Serve as technical lead for problem-solving claims issues; troubleshoot and resolve issues during operational disruptions.
- Oversee batch assignments, batch-closure operations, adjudication runs and claims reconciliation processes.
- Execute audit and universe review protocols; ensure data integrity and accuracy across all claims transactions.
- Oversees the 277CA process
- Oversee performance of systemic tools (Symkey, AMP$, EDIWORKS, SDS or other applicable tools) to ensure transparency, capability alignment, and long-term sustainability, enabling the team to operate efficiently and effectively
- Ensure SFTP process reliability for claims file transfers; monitor all inbound and outbound jobs and alert to transmission failures.
- Manage and remediate clearinghouse rejections; coordinate correction cycles with vendors and internal teams.
- Collaborate with QA and team members to identify, test, and implement new business rules to improve adjudication rates and minimize claim errors.
- Partner with Provider Contracting, Networks, and Accounting teams to resolve fee schedule, network setup, and payment processing issues.
- Collaborate with Eligibility and Authorization teams to resolve member-related issues impacting claims processing.
- Maintain comprehensive documentation of all processes, issue resolutions, and system updates.
- Recommend and implement process improvements based on operational analysis and performance metrics.
Qualifications:- Bachelor's degree or equivalent technical experience
- 5+ years in healthcare claims operations, with expertise in workflow optimization and technical troubleshooting
- Strong knowledge of claims adjudication, batch processing, EDI/clearinghouse operations, and accounting reconciliation
- Advanced understanding of SFTP/file transfer protocols and claims system architecture
- Proficiency with claims platforms, data analysis, and SQL or similar query tools preferred
- Excellent analytical, organizational, and cross-functional communication skills
- Ability to manage multiple complex issues and prioritize effectively in a fast-paced environment
Proven Personal Attributes:- Technical problem-solver with strong analytical and troubleshooting capabilities
- Proactive and detail-oriented with commitment to accuracy and process integrity
- Strong collaboration skills with ability to partner across departments and teams
- Initiative-driven with focus on continuous improvement and operational efficiency
- Reliable and accountable with strong work ethic and deadline commitment
- Self-motivated learner with ability to stay current on system and regulatory changes
- Composed and professional under pressure with strong decision-making abilities
