Manager of Claims Operations

Gravie

21d•$75,000 - $110,000

About The Position

Gravie is seeking a Manager of Claims Operations to lead the administration of their innovative self-funded health plans. This role reports into the Director of Claims Operations and encompasses the entire claims experience, focusing on exceptional customer service, accuracy, quality, and efficient processing turnaround times. The Manager will partner with the Director on the transformation of the claims function, owning execution within their team: modernizing workflows, building scalable processes, and turning operational insight into lasting improvement. This role also involves collaborating with other leaders within the Health Plan Operations Team and building strong partnerships with Pharmacy, Gravie Care, Account Management, and Network partners.

Requirements

Bachelor's Degree or equivalent experience
Subject matter expertise of medical claims knowledge and understanding end-to-end processes
At least 5 years of substantial experience in claims, including previous experience managing a team or equivalent experience as a leader for an operational team
Strong understanding of self- and level-funded health plans
Strong problem-solving skills
Commitment to providing amazing member experiences and touchpoints
Excellent communication skills
Demonstrated success getting results through collaboration

Nice To Haves

Previous startup company experience
Previous experience with Stop-Loss claim processing
Previous leadership at a TPA
Experience with Javelina as a claims processing system

Responsibilities

Lead and Enhance Daily Claims Processing: Ensure all claims are processed in a timely, accurate manner. Develop and refine end-to-end medical claims processes, including adjudication, pend workflows, and payment.
Optimize Inventory Management: Create an advanced inventory management system that supports transparent reporting and aligns with key performance indicators (KPIs).
Manage Complex Claims: Oversee complicated and high-dollar claims and address escalations effectively. Track issues from discovery through root cause resolution and remediation.
Analyze Claims Data: Gather insights from data analysis to report on key metrics, identify risks, and propose improvements.
Drive Process Improvements: Collaborate with various teams to identify and implement process enhancements, ensuring high quality and timely claim processing while meeting service level agreements.
Ensure Compliance and Accuracy: Maintain performance standards with our Auditing team and internal policies to verify correct payments, proper authorizations, and resolution of any system holds. Work closely with Compliance to ensure all processes meet or exceed regulatory requirements.
Develop Claims Team: Coach and mentor a high-performing claims team consisting of both Gravie employees and vendor partners, fostering accountability, collaboration, and professional growth.
Implement Training Programs: Establish comprehensive training for new hires and continuous development opportunities for existing staff.
Collaborate Across Teams: Work closely with configuration, optimization, finance, pharmacy, and network partners to streamline operations. Provide claims support for new products and business initiatives, ensuring smooth integration.
Prioritize Member Experience: Approach every decision with a member-first mindset, ensuring that their needs are at the forefront of your actions.
Embody Core Values: Demonstrate our core competencies: authenticity, curiosity, creativity, empathy, and a focus on outcomes.