Job Summary
We are seeking an experienced Claims Manager with a strong background in Third-Party Administrator (TPA) and specialty benefits to lead and manage a team of claims adjudicators. This role is ideal for a hands-on leader looking to play a key role in ensuring operational excellence, regulatory compliance, and team performance in a dynamic, and rapidly growing and evolving environment.
Primary Responsibilities
- Manage, mentor, and lead a team of claims adjudicators to meet quality and productivity goals.
- Provide ongoing training, coaching, and performance evaluations to team members.
- Promote a collaborative and accountable team culture.
- Oversee the end-to-end adjudication of medical, dental, pharmacy, or other specialty benefit claims.
- Ensure timely and accurate processing according to plan documents, policies, and regulatory requirements.
- Resolve complex or escalated claims issues and appeals.
- Utilize and optimize both a custom homegrown claims system and the Plexus Claims system .
- Collaborate with IT and business analysts on system updates, enhancements, and issue resolution.
- Participate in UAT and QA testing for system changes and new feature rollouts.
- Identify process inefficiencies and implement best practices for continuous improvement.
- Ensure adherence to HIPAA, ERISA, CMS, and other applicable regulatory standards.
- Develop and maintain SOPs, training documentation, and quality audit tools.
- Monitor key performance indicators (KPIs) related to claims turnaround times, accuracy, and productivity.
- Provide regular reporting to senior leadership and contribute to strategic planning initiatives.
Education and Experience
Bachelor's degree in Business Administration, Healthcare Management, or related field preferred.Minimum 5 years of experience in health or specialty benefit claims adjudication, with at least 2 years in a management or team lead role.Proven experience working with TPA operations and self-funded benefit plans.Hands-on experience with Plexus Claims system and / or a custom homegrown claims platform is required.Certified Claims Professional (CCP) or equivalent designation.Experience with configuration and system testing in Plexus or similar platforms.Exposure to automation, AI-assisted adjudication tools, or workflow optimization platforms.