Claims Manager

WM MICHAEL STEMLER INC; Fresno (CA); On-site; USD 72,000 - 78,000; Full time

Job summary

Delta Health Systems (DHS) seeks an experienced Claims Manager to lead day-to-day operations for the Stockton and Fresno offices, driving operational excellence and staff development.

You will mentor teams, manage performance, ensure adherence to policies, and collaborate with clients and internal partners to improve service delivery and claims processing quality.

Qualifications

• Two to four years of management and claims experience.
• Computer literacy with spreadsheets and word processing.
• Excellent written and verbal communication skills.
• Strong leadership and interpersonal abilities with clients and colleagues.
• Knowledge of self-funded payer claims policies and relevant regulations (TPL, COB).
• Experience with automated claims systems and maintaining production operations.

Responsibilities

• Supervise staff with training, planning, and performance appraisal.
• Mentor staff, provide corrective action, and address discipline when needed.
• Participate in hiring processes for new staff.
• Conduct monthly 1:1s, and quarterly/annual performance reviews.
• Respond to inquiries and provide timely resolutions.
• Monitor department performance and take corrective action as needed.
• Ensure inventory and queues are handled according to guidelines.
• Review reports for accuracy and timeliness; adjust measurements as needed.
• Interpret plan provisions and recommend system improvements for claims flow.
• Develop cross-department relationships for effective communication.
• Maintain relationships with customers and partners.
• Manage within the established unit budget.
• Collaborate with IT on system enhancements and provide documentation.
• Assist Client Services with requests to meet deadlines.
• Participate in new business implementations and meetings.
• Uphold policies, follow CBAs, and contribute to department training.

Skills

Leadership

Communication

Computer literacy

Interpersonal skills

Claims policy knowledge

Automated claims systems

Job description

Job Location: Fresno Claims Office - Fresno, CA, Position Type: Full Time, Salary Range: $72384.00 - $78000.00Hourly, Job Category: Management, Delta Health Systems (DHS), one of the nation’s leading Third Party Administrators (TPAs) for self-funded health plans, is seeking an experienced and collaborative leader to join our team as Claims Manager. This position oversees day-to-day operational functions for our Stockton and Fresno offices and plays a key role in driving operational excellence, team development, and customer satisfaction.

Essential Duties and Responsibilities

• Supervise assigned staff in a responsible manner including training, planning, directing work, appraising performance, rewarding, and addresses complaints.
• Mentors, educates, and provides corrective action, performance improvement plans, and disciplines staff when necessary.
• Participants in the interview process for the hiring of new staff when necessary.
• Conducts monthly 1:1, quarterly, and annual performance reviews with staff to discuss productivity, issues, concerns, quality, and expectations.
• Responds to staff, internal and external customer inquiries, and provides resolution to issues accordingly.
• Evaluates department performance and takes corrective action, when necessary,
• Ensures overall inventory and assigned queues and processes are handled within department guidelines.
• Reviews department reports for accuracy, thoroughness, and timeliness and adjusts measurements when necessary.
• Interprets plan provisions and make recommendations for system administrative improvements to meet customer expectations.
• Develop relationships with other departments to ensure interdepartmental communication is effective.
• Develops and maintains effective relationships with customers and their affiliated partners.
• Manages within established budget of unit.
• Collaborates with information services on system enhancements, providing documentation and justification for improvements to system for proper claims flow.
• Assists Client Services with client requests to meet customer expectations, requests, and deadlines.
• Participate in new business implementations.
• Enforces, adheres to, and follows department policies and procedures and Collective Bargaining Agreements.
• Participates in and contributes to department meetings and continual training.
• Represents company at existing and prospective customer meetings.
• Upholds and exemplifies company values.
• Must occasionally travel to client locations.
• Performs other duties as assigned.

Qualifications

• Two to four years of management and claims experience.
• Must be computer literate w/proficiency in spreadsheet and word processing applications.
• Excellent written and verbal communication skills.
• Must have excellent leadership abilities and interpersonal skills; ability to establish confidence, rapport and foster cooperative relationships with clients, providers, and co-workers.
• Must understand self-funded payer claims policies as well as Federal, State and other regulations pertaining to health insurance claims payment including TPL, COB, and coding and reimbursement methodologies.
• Experience with automated claims systems; and ability to maintain sound production operations also required

Supervision

This position reports directly to a Stockton Claims Manager, limited supervision with considerable responsibility for work quality and quantity.