PPO Medical Claims Manager
About The Position
MPI is seeking an experienced Medical Claims Manager to lead our Claims team in Studio City, CA. This onsite leadership role is responsible for overseeing day-to-day claims operations, ensuring accurate and timely processing, compliance, and staff development. The ideal candidate brings a strong background in PPO medical insurance claims management, with proven expertise in systems such as QNXT (or similar claim platforms), CPT/ICD-10 coding, coordination of benefits, and HIPAA compliance. You will play a key role in shaping department workflows, mentoring claims staff, and partnering with leadership to support MPI’s mission of delivering exceptional service to our participants.
Requirements
- Bachelor’s degree or equivalent combination of education and experience.
- Minimum 7 years of people management experience leading a team who process and adjudicate PPO medical claims for a payer, including hiring, training, and staff development.
- 5–7 years of experience with PPO medical claims Payer systems, benefit configuration, and claims adjudication requirements (7+ years preferred).
- 3+ years’ experience with QNXT or a comparable claims system.
- Strong knowledge of CPT, ICD-10, COB, and medical terminology.
- Advanced proficiency in Microsoft Office Suite (Excel, Word, Outlook).
- 7+ years’ experience with HIPAA and privacy compliance.
- Excellent communication skills, with strong analytical and problem-solving abilities.
- Ability to thrive in a fast-paced environment with strict attention to detail.
- Flexibility to work extended hours as required.
- Ability to interact with all levels of employees including entry level staff and. senior management
Responsibilities
- Lead daily operations of the claims department, including staffing, workflow, production, and team support.
- Manage and coach a team of claims examiners, processors, and clerical staff.
- Oversee QNXT claims processing inventory for manually adjudicated claims and ensure system accuracy.
- Collaborate with the Director of Medical Claims to set department goals, improve processes, and implement system enhancements.
- Monitor compliance with HIPAA, privacy regulations, and industry standards.
- Partner with vendors (such as Anthem) and internal teams to recommend benefit configurations and resolve escalated issues.
- Support appeals, benefits-related inquiries, and regulatory audits.
- Develop and present reports for senior leadership and the Board of Directors.
- Represent the Claims department in cross-functional meetings.
Benefits
- MPI offers a comprehensive benefits package, including free medical, dental, and vision coverage, generous paid time off, retirement benefits, and professional development opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Number of Employees
251-500 employees
