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Claims Manager- HYRBID

Claims Manager- HYRBID

Sierra Solutions GroupMiami, FL, US
17 days ago
Job type
  • Full-time
Job description

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.
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    Claim Manager • Miami, FL, US