The Claims Manager will report to the Health Manager and Director of Operations.

Primary duties will include, but are not be limited to: managing the staff of the claims department, ensuring claims are processed according to turnaround times, quality and productions standards set by the Company.

Other duties include monitoring and distributing of work among the claims staff, , reviewing high dollar claims, reviewing requests for adjustments on prior claim payments, reviewing requests for claim payment exceptions and reporting on claims activity as required. Other duties will include, but not be limited to, computer upgrade projects, administration and clerical work, and liaising with other sections as required. 

Duties & Responsibilities

 Oversees overall work flow of the Claims Department

         Monitors claims and auditing turn around times to ensure objectives are being met

         Communicates daily inventory to the Health Manager and Director of Operations (“DIO”) or other assigned designee in the absence of the DIO

         Confirms all Industry reference material is updated accordingly

         Confirms all overpayments and follow up requests are handled on a timely basis

         Reports pended claims exceeding $25K

         Communicates staffing issues/concerns to the Health Manager and Director of Operations (“DIO”) or other assigned designee in the absence of the DIO

         Maintains proper employee documentation

         Conducts bi-monthly desk checks on all departmental employees

         Identifies training needs within the department and communicates them to the Health Manager and Director of Operations (“DIO”) or other assigned designee in the absence of the DIO

         Reviews daily mail log to identify any high dollar claims meeting the external medical review criteria and handles accordingly and ensures proper Executive Management is notified

         Reviews supervisory level high dollar claim

         Reviews and responds to inquiries from claims staff and other departments

         Reviews requests for adjustments on prior claim payment

         Reviews request for claim payment exceptions

 Manages assigned claims staff including coaching, performance management, discipline, employee relation issues, timely and accurate completion of employee evaluations, provides claims staff with monthly overall performance results Identifies and establishes processes and procedures to ensure efficiency and consistency throughout the Claims department and reviews for currency and relevance on an ongoing basis

         Sets goals and objectives for Claims Department and individual employees and reviews and modifies on an ongoing basis

         Participates in the recruitment process and contributes to the decision making process on appointment recommendations

 Identifies training needs and communicates these to the Health Manager and Director of Operations (“DIO”) or other assigned designee in the absence of the DIO

         Conducts performance reviews with employees as required, taking disciplinary action if necessary, and also ensures completion of the annual appraisal discussions and forms within requireddeadlines

 Negotiates additional provider discounts when necessary

 Handles special projects assigned by Management

 Participates in meetings with Executive and other Managerial staff, clients, vendors and consultants as required

 Assists with the establishment of provider/facility arrangements as required

 Undertakes other duties to support primary functions and other work as assigned to support the activities of BritCay Medical as required

The Ideal Candidate


Minimum of 10 years medical claims processing experience and knowledge of both local and overseas claims (specifically US claims) and an understanding of various fee schedules applicable to the local market

Minimum of 10 years medical claims management of a claims operation and customer service experience with demonstrable proactive management skills and the ability to problem solve

A thorough understanding of group health benefits, including medical, dental, vision, prescription, life and disability

Strong knowledge of and currency with ICD-9-10, CPT and ADA coding and medical terminology

Proven ability to train, coach and lead a diverse staff

Superior communication (including written, verbal and presentation) including the ability to manage the communication process with subordinates, peers and senior management

Excellent organizational and decision making skills are essential

A positive service-oriented approach to customer service delivery

Ability to interpret operative and pathology reports

Ability to work under pressure and multi-task

Strong English and Math skills

Proficiency in Microsoft Word & Excel as well as experience with the use of email software ?

Education & Qualifications

Bachelors Degreerequired.

Certification or a professional qualification in health insurance, or significant progress towards a relevant professional qualification is preferred

References and background check required.

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