The JobThe
Program Manager - Claims is accountable for claims escalations, provider abrasion, service issues, pricing, payment policy interpretation, and the investigation and resolution of complex, high-dollar claims. This role ensures claims are adjudicated according to policies, contracts, and regulatory requirements; collaborates with internal and external partners to resolve issues; and analyzes data to identify trends, operational problems, cost savings, and process improvement opportunities.
The position leads claims triage and management for AEP/OEP, supports Total Cost of Care initiatives, and works directly with senior leadership to develop resolution solutions for escalated cases
You Will- Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation.
- Investigate and resolve complex, high-dollar claims and ensure claims are adjudicated according to policies, contracts, and regulatory requirements.
- Work with providers, members, Medical Management, Coding, Billing, and Finance to resolve claims issues.
- Analyze claims and operational data to identify trends, operational problems, cost savings, and process improvement opportunities.
- Collaborate with Network Management and work directly with external partners, as needed, to address claims-related issues.
- Lead claims triage and management for the Annual Enrollment Period and Open Enrollment Period (AEP/OEP).
- Support Total Cost of Care initiatives by identifying and implementing opportunities to improve efficiencies.
- Support staffing plans and resource allocation for claims programs and initiatives.
- Manage vendor or third-party claims relationships, when applicable.
- Support system implementations and claims-platform upgrades, including leading testing and workflow changes, and partner with senior leadership to develop resolution solutions for escalated cases.
- We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
- Actively support the achievement of SCAN's Vision and Goals.
- Other duties as assigned.
Your Qualifications- Bachelor's Degree or equivalent experience in Business Administration, Healthcare Administration, Finance, or a related field; or an equivalent combination of education and experience.
- 2-3 years of leadership experience.
- 5 or more years of progressive experience in healthcare claims operations, claims analysis, or a related health plan function.
- Experience managing cross-functional programs, complex claims issues, vendors, or claims-related initiatives.
- Experience with Medicare Advantage claims operations and regulatory requirements preferred.
- Strong knowledge of claims adjudication, claims operations, pricing, and applicable policies, contracts, and regulatory requirements.
- Ability to interpret National Coverage Determinations and Local Coverage Determinations (NCD/LCD) and other payment policies.
- Demonstrated ability to investigate and resolve complex, high-dollar, and escalated claims.
- Strong analytical skills with the ability to identify trends, operational problems, cost savings, and process improvement opportunities.
- Ability to collaborate effectively with providers, members, Medical Management, Coding, Billing, Finance, Network Management, vendors, and external partners.
- Program and project management skills, including the ability to lead multiple priorities and deliver results.
- Ability to support staffing plans, and resource allocation.
- Experience supporting system implementations, testing, claims-platform upgrades, and workflow changes.
- Strong written and verbal communication skills, including the ability to present issues and resolution solutions to senior leadership.
- Ability to work independently, exercise sound judgment, and manage sensitive or highly escalated matters.
- Leadership - Skilled to develops others
- Problem Solving - Strong problem-solving skills
- Optimizes Work Processes - Identifies and creates processes necessary to get work done
- Advanced Microsoft Office Suite, Visio, and SQL experience are required.
What's in it for you?- Base salary range: $106,200 to $153,705 per year
- Work Mode: Mostly Remote
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
- Excellent 401(k) Retirement Saving Plan with employer match and contribution
- Robust employee recognition program
- Tuition reimbursement
- An opportunity to become part of a team that makes a difference to our members and our community every day!
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
At
SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
