Manager, Claims

HMSA • Honolulu, HI

110d

About The Position

The position involves managing and leading a claims team, providing training, mentorship, and best practice solutions. The role requires overseeing daily operations of the claims team, including inventory analysis, tracking, and resolution of claims. The individual will serve as the escalation point for complex or disputed claims and drive resolution within defined service level agreements (SLA). Additionally, the position entails monitoring and analyzing key performance indicators (KPIs) and taking corrective actions to improve efficiency, accuracy, and customer satisfaction. Collaboration with key stakeholders, including underwriting, lines of business (LOB), legal, and servicing teams, is essential to ensure a consistent and integrated approach to accurate and timely claims processing. The role also includes maintaining documentation, audit trails, and reporting in line with internal controls and external compliance requirements, as well as contributing to the development and implementation of new policies, procedures, and systems to improve claims operations.

Requirements

• Bachelor's degree and seven years of related work experience; or equivalent combination of education and related work experience.
• Five years of management/supervisory experience.
• Expert experience developing and presenting actionable solutions to complex problems with C-Suite level.
• Effective written and verbal communication skill, including the ability to communicate and present complex issues in a concise and easy to understand manner.
• In-depth knowledge of managed care, PPO, HMO, Medicaid, Medicare Advantage, and commercial group health plans.
• Strong working knowledge of claims adjudication systems (e.g., Facets, QNXT, Epic Tapestry, HealthEdge).
• Expert knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources.
• Intermediate knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.

Responsibilities

• Manage and lead a claims team by providing training, mentorship, and best practice solutions.
• Manage daily operations of the claims team, including inventory analysis, tracking and resolution of claims.
• Serve as the escalation point for complex or disputed claims and drive resolution within defined SLA.
• Monitor and analyze key performance indicators (KPIs) and take corrective actions to improve efficiency, accuracy, and customer satisfaction.
• Collaborate with key stakeholders to include underwriting, LOB, legal, servicing teams to ensure a consistent and integrated approach to accurate and timely claims processing.
• Maintain documentation, audit trails, and reporting in line with internal controls and external compliance requirements.
• Contribute to the development and implementation of new policies, procedures, and systems to improve claims operations.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees