The Claims Manager is responsible for overseeing the end-to-end claims operations within the MSO managed care delegated functions. This role provides guidance on healthcare claims adjudication and payment processing for Medi-Cal, Medicare, PACE, and other lines of business based on member Evidence of Coverages (EOC) and CMS/DHCS guidelines, ensures that claims are processed accurately, timely, and in compliance with regulatory requirements and contractual obligations. The Claims Manager will lead the claims team, implement process improvements, and collaborate with internal and external stakeholders to optimize claims adjudication workflows.
This role requires high-level of decision-making and problem-solving skills in relates to claims operations, compliance, and process improvements. Deep understanding of Medi-Cal, Medicare Advantage, PACE, CMS, and DHCS regulations; ensuring full compliance across the department. Ability to manage multiple priorities, oversee department workflows, and optimize resource allocation. Responsible to design training programs for claims teams and leads initiatives to enhance team expertise. Excellent communication skills to interact with leadership, payers, providers, auditors, and MSO internal departments.
ESSENTIAL JOB FUNCTIONS:
- Oversee managed care claims processing, ensuring compliance with CMS, DHCS, and health plan guidelines.
- Monitor claims adjudication, ensuring accuracy, timeliness, and regulatory adherence.
- Develop and implement policies and procedures to improve claims processing efficiency.
- Work with IT and system vendors to optimize claims processing systems and troubleshoot issues.
- Lead and mentor the claims team, including Claims Supervisors and processors, ensuring high performance and engagement.
- Conduct regular performance evaluations, design training programs, provide training, and develop staff competencies.
- Establish and monitor productivity metrics to enhance team efficiency.
- Serve as the primary liaison with health plans, providers, auditors, and third-party administrators to resolve claims issues and disputes.
- Manage escalations, appeals, and grievances related to claims processing.
- Coordinate with provider relations to address claims denials and payment disputes.
- Identify areas for process improvement and implement best practices to enhance claims adjudication.
- Analyze claims data, trends, and key performance indicators to drive operational enhancements.
- Prepare reports for senior management on claims performance, backlog, and issue resolution.
- Direct supervision of a department involving responsibility for results in terms of costs, methods and personnel. Responsible for carrying out supervisory/managerial responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing and hiring of employees; planning, assigning, scheduling, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
- Performs other job duties as required by manager/supervisor.
QUALIFICATIONS:
- Bachelor’s degree in business, healthcare administration, or related field is preferred; Associate’s degree may be considered with relevant, equivalent work experience.
- Experience: Minimum of 5 years in managed care claims and compliance field, with at least 3 years in a managerial role within an IPA, health plan, medical group, or TPA.
- Knowledge of: Medi-Cal and MA claims processing, CMS and DHCS regulations, capitated vs. fee-for-service (FFS) models, claims adjudication systems (e.g., EZ-CAP, HealthEdge, Tapestry, or similar).
- Skills: Strong analytical, problem-solving, and leadership skills. Proficiency in Excel, reporting tools, and claims systems.
- Certifications (Preferred): AAHAM, CPC, or other relevant claims-related certifications.
LANGUAGE:
- Must be able to fluently speak, read and write English.
- Fluency in other languages are an asset.
STATUS:
- This is an FLSA Exempt position.
- This is not an OSHA high-risk position.
- This is a full-time position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).