Claims Manager - Figherfighter's Health Plan

Local 1014 Medical Plan; El Monte (CA); On-site; USD 110,000 - 140,000; Full time

Benefits offered by this job

100% covered benefits for employee and

Dependent coverage

IRA contributions (7%–9%)

Paid time off: 2 weeks vacation, 10 S,

Office hours Mon–Fri 8:30 AM–4:30 PM

Job summary

Local 1014 Medical Plan in Los Angeles County, El Monte, CA, seeks a Claims Manager to lead a diverse claims team in a fast-paced, on-site environment.

The role focuses on regulatory compliance, process improvements, and effective customer service for plan members and providers. The ideal candidate has extensive claims leadership experience in health plans and strong collaboration with stakeholders.

Qualifications

• Minimum of four years of managing claims personnel in health insurance or managed care.
• Minimum 10 years of claims processing/adjudication experience.
• Proficiency with EDI and paper claim lifecycles in health insurance.
• Baseline knowledge of HIPAA and ERISA regulations.
• Experience with Basys and WGS systems preferred.
• Strong leadership and communication abilities.
• Ability to manage staff performance and conduct.
• Detail-oriented with excellent time management.

Responsibilities

• Lead a team of MSRs, adjusters, and auditors to meet regulatory and service standards.
• Oversee call flow, workflows, productivity, and member feedback; drive improvements.
• Handle escalated complaints as a technical expert.
• Manage personnel tasks: timecards, PTO, evaluations, discipline, hiring/terminations.
• Identify system/workflow improvements and implement best practices.
• Develop and deliver staff training and corrective action plans.
• Collaborate with Board, Trustees, and other stakeholders.
• Assist in implementing new Health Trust service offerings.

Skills

Leadership

Customer service

Regulatory compliance

Communication

Team management

Problem solving

Time management

Staff development

Education

Bachelor's degree preferred

Equivalent qualifying experience

Tools

Basys

WGS claim system

Taft-Hartley knowledge

Job description

Local 1014, the self-funded ERISA Trust dedicated to serving the well-being of the Los Angeles County Fire Fighters and their families, is seeking a service-driven Claims Manager. The ideal candidate should have management experience in a call center environment, aiding in improving the efficiency of the Claims Department, and guide Claim Adjusters processing complex hospital, and facility claims independently and with confidence. The position is on-site in El Monte, CA.

Position Overview

As a member of the Health Trust management team, the Claims Manager is responsible for overseeing the Assistant Claims Manager, two Auditors, and an 18-person claims team, with day-to-day focus on call center and member services handling of incoming calls from plan members and providers.

Essential Job Functions

• Manage a team of member services representatives (MSRs), adjusters, and auditors, focused on consistently meeting regulatory requirements while demonstrating the standards and values of Local 1014 in their interaction with plan members, external business partners, and other areas within Local 1014.
• Oversee call flow, work processes, claim resolution productivity, and member feedback. Facilitate team training, process improvements, or documentation updates to ensure member service goals and audit objectives are met promptly.
• Act as a technical expert in handling complaints and other escalated issues from internal and external sources.
• Monitor all tasks related to personnel management, including but not limited to: timecard management, PTO approval, performance evaluations, goal setting, compliance with Local 1014's Work Rules and Codes of Conduct, counseling/discipline, and hiring/termination.
• Proactively identify potential system or workflow improvements that may enhance accuracy, productivity, and timeliness of service; implement industry best practices.
• Identify staff training needs, develop training materials as needed, and implement corrective action plans.
• Collaborate well with all levels of personnel within Local 1014, including the Board and Trustees.
• Assist in the implementation of new Health Trust service offerings.

Required Knowledge/Skills/Abilities/Experience

• Minimum of four years of managing claims personnel experience in a health insurance or managed care environment, or equivalent education/experience.
• Minimum 10 years of claims processing/adjudication with knowledge of healthcare benefits, benefit administration, and health care delivery from either a payer or provider perspective.
• Working knowledge of EDI and paper claim lifecycles and how they relate to health insurance industry practices and standards.
• Proficiency using a claims transactional system for data entry and claims processing. Proficiency in Basys and WGS claim systems (or Taft-Hartley or multiemployer trust funds experience) strongly preferred.
• Thorough knowledge of regulatory requirements for handling of claims and appeals, and protection of privacy, such as HIPAA and ERISA.
• Extensive knowledge of physician and facility billing practices, appropriate CPT coding initiatives, ICD-10 coding standards, and revenue and HCPCS coding.
• High proficiency in Microsoft Office programs — Excel, Outlook, and Word.
• Excellent leadership, interpersonal, and team-building skills.
• Superior verbal and written communication skills.
• Strong analytical ability and problem-resolution skills.
• Ability to establish and maintain positive and effective work relationships with people from many different disciplines with varying degrees of technical and clinical expertise, including coworkers, plan members, providers, and external business partners.
• Effective management of staff performance.
• Strong service orientation and ability to maintain professional composure when dealing with confrontation or complaints.
• Effective time management and organizational skills.
• Ability to work independently and handle multiple priorities simultaneously.
• Detail-oriented.

Education

Bachelor's degree preferred, but not required with equivalent qualifying experience.

Preferred Certifications

• AHIP designations such as HIA (Health Insurance Associate), PAHM (Professional, Academy for Healthcare Management), or ACS (Associate, Customer Service)
• AAPC or AHIMA coding certification (CPC, CCS, or equivalent)
• Familiarity with ERISA/HIPAA compliance training or certification is a plus

Compensation & Total Rewards (all start day 1 of employment)

• 100% covered benefits for employee and dependents
• Local 1014 contributes 7%–9% of annual income to an IRA (not deducted from your paycheck)
• 2 weeks accrued vacation, 10 sick days 13 holidays,
• Office Hours Mon–Fri, 8:30 AM–4:30 PM (some weekends may be required)
• Full-time, Exempt

Equal Employment Opportunity Statement Local 1014 is an equal opportunity employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, veteran status, or any other characteristic protected by applicable federal, state, or local law. This commitment applies to all aspects of employment, including recruitment, hiring, training, promotion, compensation, and termination.