Claims Manager
About The Position
The Claims Manager is responsible for overseeing the daily operations, performance, and regulatory compliance of the Claims Department within the Managed Services Organization (MSO). This role provides leadership and supervision to Claims Examiners and ensures the accurate, timely, and compliant adjudication of professional and institutional claims in accordance with health plan contracts, regulatory requirements, and organizational policies. The Claims Manager monitors claims inventory, production, and quality metrics, ensures adherence to turnaround time standards, and supports operational efficiency and compliance with federal and California regulatory requirements, including Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and Department of Health Care Services (DHCS) requirements where applicable. This position plays a critical role in ensuring claims processing accuracy, maintaining provider satisfaction, protecting organizational financial integrity, and supporting delegated managed care operations.
Requirements
- High School diploma or equivalent required.
- At least five years of managed care claims processing experience.
- Two or more years of supervisory or leadership experience.
- Experience processing professional and institutional claims.
- Strong knowledge of managed care claims processing and adjudication.
- Knowledge of CPT, HCPCS, ICD-10, and UB-04 claim processing standards.
- Knowledge of DMHC, CMS, DHCS, and managed care regulatory requirements.
- Strong leadership and staff supervision skills.
- Strong analytical, organizational, and problem-solving skills.
- Ability to assess workload and staffing requirements.
- Excellent written and verbal communication skills.
- Proficiency in Microsoft Office Suite, including Excel.
- Ability to manage multiple priorities in a deadline-driven environment.
- Ability to maintain confidentiality and data integrity.
- Ability to collaborate effectively with internal and external stakeholders.
Nice To Haves
- Bachelor’s degree in Healthcare Administration, Business Administration, or related field.
- Experience in MSO, IPA, or delegated managed care environment.
- Experience with Medicare, Medi-Cal, Commercial, and managed care claims.
- Experience with claims systems such as EZ Cap, EPIC, or similar platforms.
- Experience supporting regulatory and delegation audits.
- Certified Professional in Healthcare Quality (CPHQ)
Responsibilities
- Overseeing the daily operations, performance, and regulatory compliance of the Claims Department.
- Providing leadership and supervision to Claims Examiners.
- Ensuring accurate, timely, and compliant adjudication of professional and institutional claims.
- Monitoring claims inventory, production, and quality metrics.
- Ensuring adherence to turnaround time standards.
- Supporting operational efficiency and compliance with federal and California regulatory requirements.
- Maintaining provider satisfaction.
- Protecting organizational financial integrity.
- Supporting delegated managed care operations.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
