Manager, Claims Operations

Healthcare Management Administrators • Bellevue, WA

77d • $100,000 - $123,000

About The Position

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service. We are proud to say that for three years, HMA has been chosen as a ‘Washington’s Best Workplaces’ by our Staff and PSBJ™. Our vision, ‘Proving What’s Possible in Healthcare™,’ and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results.

Requirements

• Bachelor’s Degree or equivalent work experience.
• Minimum 5 years of claims operations experience, self-funded health plan experience is a plus.
• Minimum 2 years of people leading experience.
• Experience with claims platforms such as HealthEdge, Mphasis, or Facets.
• Knowledge of CPT, HCPCS, ICD-10 coding, and reimbursement methodologies.
• Strong understanding of provider contract terms, fee schedules, and pricing models (e.g., DRG, APC, RBRVS).
• Proven ability to manage and develop a team of highly skilled staff.
• Proven ability to manage and interact with vendors to support execution of work within the SLA’s established.

Responsibilities

• Oversee the end-to-end processing of healthcare claims.
• Lead the HMA Claims Operations staff and their daily work requirements.
• Leverage metrics and forecasts to prioritize workload and resourcing.
• Manage claims intake, pricing, adjudication, coordination of benefits, and issue resolution.
• Direct supervisory responsibilities: Manage and coach individual contributor’s performance and quality.
• Assess and manage claims inventory: Track and manage inventory trends and proactively adjust resource levers.
• Manage daily operations of claims processing, ensuring accuracy, timeliness, and compliance.
• Create daily updates for management team flagging production rates, critical issues, and areas of escalation.
• Monitor and resolve pricing discrepancies impacting claims adjudication and provider payments.
• Lead initiatives to improve pricing workflows, automation, and system performance.
• Lead vendor audits and manage reporting to ensure vendor quality.
• Apply subject matter expertise to the business of claims processing and operations.
• Manage vendor agreements, proactively identify and flag issues, escalate appropriately.
• Develop and maintain workflows and documentation specific to claims processing.
• Train and coach staff and vendors on claims processes as needed.
• Motivate and lead team members and vendors in accordance with HMA values and objectives.
• Proactively review and assess talent, continually develop and/or recruit talent to meet objectives.

Benefits

• Seventeen (IC) days paid time off (individual contributors).
• Eleven paid holidays.
• Two paid personal and one paid volunteer day.
• Company-subsidized medical, dental, vision, and prescription insurance.
• Company-paid disability, life, and AD&D insurances.
• Voluntary insurances.
• HSA and FSA pre-tax programs.
• 401(k)-retirement plan with company match.
• Annual $500 wellness incentive and a $600 wellness reimbursement.
• Remote work and continuing education reimbursements.
• Discount program.
• Parental leave.
• Up to $1,000 annual charitable giving match.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 101-250 employees