Program Manager - Claims, Health Plan
About The Position
The Program Manager - Claims is accountable for claims escalations, provider abrasion, service issues, pricing, payment policy interpretation, and investigating and resolving complex, high-dollar claims. The role ensures claims are adjudicated in accordance with policies, contracts, and regulatory requirements, collaborates with internal and external partners to resolve issues, and analyzes data to identify trends, operational problems, cost savings, and process improvements. The position leads claims triage and management for the Annual Enrollment Period and Open Enrollment Period (AEP/OEP), supports Total Cost of Care initiatives, and works directly with senior leadership to develop solutions for escalated cases. It also supports staffing and resource allocation, manages vendor or third-party claims relationships when applicable, and supports system implementations and claims-platform upgrades, including testing and workflow changes. The role requires a bachelor's degree or equivalent experience in a related field, leadership experience, and progressive experience in healthcare claims operations or a related health plan function. Advanced Microsoft Office Suite, Visio, and SQL experience are required. The position is mostly remote.
Requirements
- Bachelor's degree or equivalent experience in Business Administration, Healthcare Administration, Finance, or a related field; or an equivalent combination of education and experience.
- 2–3 years of leadership experience.
- 5 or more years of progressive experience in healthcare claims operations, claims analysis, or a related health plan function.
- Experience managing cross-functional programs, complex claims issues, vendors, or claims-related initiatives.
- Strong knowledge of claims adjudication, claims operations, pricing, and applicable policies, contracts, and regulatory requirements.
- Ability to interpret National Coverage Determinations and Local Coverage Determinations (NCD/LCD) and other payment policies.
- Demonstrated ability to investigate and resolve complex, high-dollar, and escalated claims.
- Strong analytical skills and ability to identify trends, operational problems, cost savings, and process improvement opportunities.
- Ability to collaborate effectively with providers, members, Medical Management, Coding, Billing, Finance, Network Management, vendors, and external partners.
- Program and project management skills, including ability to lead multiple priorities and deliver results.
- Ability to support staffing plans and resource allocation.
- Experience supporting system implementations, testing, claims-platform upgrades, and workflow changes.
- Strong written and verbal communication skills, including ability to present issues and resolution solutions to senior leadership.
- Ability to work independently, exercise sound judgment, and manage sensitive or highly escalated matters.
- Leadership skills, including developing others.
- Strong problem-solving skills.
- Ability to optimize work processes by identifying and creating processes necessary to get work done.
- Advanced Microsoft Office Suite, Visio, and SQL experience.
Nice To Haves
- Experience with Medicare Advantage claims operations and regulatory requirements.
Responsibilities
- Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation.
- Investigate and resolve complex, high-dollar claims and ensure claims are adjudicated according to policies, contracts, and regulatory requirements.
- Work with providers, members, Medical Management, Coding, Billing, and Finance to resolve claims issues.
- Analyze claims and operational data to identify trends, operational problems, cost savings, and process improvement opportunities.
- Collaborate with Network Management and external partners as needed to address claims-related issues.
- Lead claims triage and management for the Annual Enrollment Period and Open Enrollment Period (AEP/OEP).
- Support Total Cost of Care initiatives by identifying and implementing opportunities to improve efficiencies.
- Support staffing plans and resource allocation for claims programs and initiatives.
- Manage vendor or third-party claims relationships when applicable.
- Support system implementations and claims-platform upgrades, including leading testing and workflow changes.
- Partner with senior leadership to develop resolution solutions for escalated cases.
- Actively support the achievement of SCAN’s Vision and Goals.
- Perform other duties as assigned.
Benefits
- Annual employee bonus program
- Robust Wellness Program
- Generous paid time off (PTO)
- Eleven paid holidays per year, plus one floating holiday and one birthday holiday
- 401(k) retirement savings plan with employer match and contribution
- Employee recognition program
- Tuition reimbursement
- Inclusive benefits
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What This Job Offers
Job Type
Full-time
Career Level
Manager
