Claims Operations Manager
TEKsystems•Honolulu, HI
•$30 - $32•Hybrid
About The Position
The Claims Operations Manager is responsible for overseeing the end-to-end claims processing function within a healthcare payer environment. This role ensures accurate, timely adjudication of claims, drives process improvements, and manages vendor relationships to optimize operational efficiency and service quality. The ideal candidate brings strong knowledge of healthcare claims workflows, a continuous improvement mindset, and experience working in fast-paced operations environments.
Requirements
- Experience in healthcare claims operations within a payer organization
- Strong understanding of claims processing workflows and adjudication concepts
- Knowledge of healthcare regulations, coding basics (ICD, CPT, HCPCS), and reimbursement methodologies
- Demonstrated ability to analyze processes and implement improvements
- Experience managing operational metrics and performance targets
- Strong analytical and problem-solving skills
- Excellent communication and stakeholder management abilities
- Ability to manage multiple priorities in a fast-paced environment
- Detail-oriented with a focus on accuracy and quality
- Results-driven with a continuous improvement mindset
Nice To Haves
- Prior supervisory or team leadership experience
- Hands-on experience with claims adjudication systems (e.g., QNXT, Facets, or similar platforms)
- Experience working with third-party vendors or outsourced operations
- Lean, Six Sigma, or process improvement certifications (a plus)
- Previous experience working/managing offshore teams and familiarity with claims adjudication systems (QNXT, Facets, Epic Tapestry, HealthEdge, etc.,)
Responsibilities
- Manage daily claims operations, including intake, adjudication, adjustments, and issue resolution
- Ensure claims are processed accurately, efficiently, and in compliance with regulatory and internal guidelines
- Monitor key performance indicators (KPIs) such as turnaround time, accuracy, and backlog
- Identify inefficiencies and implement process improvements to enhance productivity, quality, and cost-effectiveness
- Partner with internal stakeholders to streamline workflows and reduce manual intervention
- Support automation, system enhancements, and operational transformation initiatives
- Oversee third-party vendors and business partners supporting claims processing
- Track vendor performance against SLAs and KPIs
- Collaborate with vendors to resolve escalations and improve service delivery
- Provide guidance, coaching, and support to claims staff (if applicable)
- Foster a high-performance, collaborative team environment
- Support workforce planning, training, and talent development initiatives
- Work closely with Provider Relations, Customer Service, Compliance, and IT teams
- Assist in resolving complex claims issues and escalations
- Participate in audits, compliance reviews, and reporting activities
Benefits
- Medical, dental & vision
- Critical Illness, Accident, and Hospital
- 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
- Life Insurance (Voluntary Life & AD&D for the employee and dependents)
- Short and long-term disability
- Health Spending Account (HSA)
- Transportation benefits
- Employee Assistance Program
- Time Off/Leave (PTO, Vacation or Sick Leave)
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Upload and Match Resume
What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
