Claims Manager

AIDS Healthcare Foundation•Los Angeles, CA

About The Position

Claims Department Manager enhances the reputation of AHF by meeting key respobsibities as assigned by department management. You will be a passionate advocate for our top initiatives. To be successful as the Claims Department Manager , it is crucial to ensure that the AHF Core Values and Mission stay top of mind with all that you do. At AHF, we are nimble and able to adapt in a dynamic environment to assist in providing the best experience for our clients and workplace for our employees. AHF has a collaborative organizational structure where staff are accountable to multiple leaders. The Claims Department Manager will work as a part of a close-knit team to description Key Responsibilities: Team Leadership & Supervision Manage, coach, and develop a team of claims examiners and department support associates. Monitor performance metrics and conduct regular performance evaluations. Foster a culture of accountability, collaboration, and continuous improvement. Ensure timely and accurate processing of provider claims in accordance with plan policies and regulatory requirements Oversee daily inventory management to ensure workloads are balanced and service levels are met. Monitor and manage claim denials, rework, and appeals/disputes processes. Ensure compliance with all regulatory requirements. Quality Assurance & Auditing Implement and oversee internal audits to ensure claims accuracy and identify trends or training needs. Collaborate with the Quality and Compliance teams to address audit findings and implement corrective actions. System & Process Management Partner with IT and vendors to ensure claims system functionality, updates, and issue resolution. Identify and implement process improvements to enhance efficiency and reduce errors. Provider & Stakeholder Relations Serve as a liaison with providers to resolve claim disputes and ensure timely communication. Collaborate with Provider Relations, Member Services and UM/Medical Management to address cross-functional issues. Reporting & Analytics Generate and analyze operational reports to track productivity, turnaround times, and denial trends. Present findings and recommendations to leadership for strategic planning. Other Duties Perform other related duties and special projects as assigned to support departmental and organizational goals.

Requirements

3-5 years of Claims Management experience preferred.

Responsibilities

Team Leadership & Supervision
Manage, coach, and develop a team of claims examiners and department support associates.
Monitor performance metrics and conduct regular performance evaluations.
Foster a culture of accountability, collaboration, and continuous improvement.
Ensure timely and accurate processing of provider claims in accordance with plan policies and regulatory requirements
Oversee daily inventory management to ensure workloads are balanced and service levels are met.
Monitor and manage claim denials, rework, and appeals/disputes processes.
Ensure compliance with all regulatory requirements.
Quality Assurance & Auditing
Implement and oversee internal audits to ensure claims accuracy and identify trends or training needs.
Collaborate with the Quality and Compliance teams to address audit findings and implement corrective actions.
System & Process Management
Partner with IT and vendors to ensure claims system functionality, updates, and issue resolution.
Identify and implement process improvements to enhance efficiency and reduce errors.
Provider & Stakeholder Relations
Serve as a liaison with providers to resolve claim disputes and ensure timely communication.
Collaborate with Provider Relations, Member Services and UM/Medical Management to address cross-functional issues.
Reporting & Analytics
Generate and analyze operational reports to track productivity, turnaround times, and denial trends.
Present findings and recommendations to leadership for strategic planning.
Other Duties
Perform other related duties and special projects as assigned to support departmental and organizational goals.