Manager, Claims Processing

CenterWell • Miramar, OH

8d • Onsite

About The Position

The Manager, Claims Processing reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Manager, Claims Processing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals. The Manager, Claims Processing is responsible for leading and overseeing the end-to-end claims adjudication and processing function for a TPA organization. This role manages professional and/or supervisory-level associates and ensures timely, accurate, and compliant processing of complex and specialty home health, DME, home infusion and SNF claims submitted via electronic and paper formats. The Manager applies advanced technical and regulatory knowledge of Medicare, Medicaid, and commercial payers to resolve moderately complex claims issues, optimize workflows, and improve departmental performance. Responsibilities are executed within established policies and practices, with a planning horizon of less than 24 months.

Requirements

• Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field, or equivalent combination of education and experience.
• 5+ years of progressive experience in claims processing, billing, or revenue cycle management within home health, DME, home infusion, SNF or related healthcare settings.
• 2 or more years of people management experience
• Comprehensive knowledge of all Microsoft Office applications, including Word, Project and Visio
• Strong working knowledge of Medicare, Medicaid, and commercial insurance reimbursement, EDI claims, and healthcare billing systems
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Nice To Haves

• Project Management experience
• Six Sigma certification

Responsibilities

• Oversee the review, adjudication, and resolution of home health, DME, home infusion and SNF claims, including Medicare, Medicaid, and commercial payer claims, ensuring compliance with payer guidelines, CMS regulations, and organizational policies.
• Determine whether claims are paid, denied, returned, or adjusted based on clinical documentation, coding accuracy, authorization status, and payer requirements.
• Manage escalated, complex, or high-risk claims issues, including denials, underpayments, and payer disputes.
• Manage and develop claims processing professionals and/or claims supervisors; set performance expectations, provide coaching, and conduct performance reviews.
• Coordinate team activities to ensure department goals, productivity metrics, accuracy standards, and service-level agreements are met.
• Identify staffing, training, and resource needs; make tactical decisions related to workload distribution and prioritization.
• Identify, lead, and implement change initiatives to improve claims processing efficiency, denial rates, turnaround times, and cash flow.
• Analyze claims trends, denial patterns, and payer policies; partner with Revenue Cycle, Clinical, Compliance, and Authorization teams to address root causes.
• Use advanced analysis and independent judgment to solve moderately complex operational and technical problems within established policies.
• Collaborate with Coding, Clinical Operations, Intake, Authorization, Finance, and Compliance teams to ensure accurate documentation and clean claim submission.
• Maintain frequent contact with peer managers and senior professionals across departments to align on workflows, regulatory updates, and payer changes.
• Participate in cross-department meetings, briefings, and audits related to billing and claims performance.
• Ensure adherence to Medicare Conditions of Participation (CoPs), CMS Claims Processing Manual guidance, HIPAA, and payer-specific rules.
• Support internal and external audits by maintaining accurate documentation and providing claims data and analyses as requested.
• Monitor KPIs such as days in A/P, first-pass yield, denial rates, and rework volume; report results to department leadership.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Manager