Claims Operations Lead

Verda Healthcare; Huntington Beach (CA); In loco; USD 95.000 - 120.000; Tempo pieno

Vantaggi offerti da questo lavoro

401(k)

Paid time off (vacation, holiday, sick

Health insurance

Dental insurance

Vision insurance

Life insurance

Descrizione del lavoro

Verda Healthcare, Inc. is a Medicare Advantage Prescription Drug Plan (MAPD) organization focused on underserved communities.

The Assistant Director, Claim Operations supports the Claims Director in daily oversight of claims processing, ensuring accuracy, timeliness, and CMS/compliance adherence. This role provides operational, administrative, analytical, and project support across dashboards, audits, and reporting, collaborating with Claims Operations, Provider Relations, Compliance, Finance,

Competenze

• Bachelor’s degree or equivalent in related field; preferred.
• Minimum 3+ years of experience in health plan, managed care, Medicare Advantage, IPA, TPA, or claims operations environment.
• Working knowledge of claims intake, adjudication, pricing, payment, reconciliation, denials, pending, and provider dispute workflows.
• Familiarity with CMS, state, health plan, and delegated entity requirements related to claims administration is preferred.
• Experience using claims systems and reporting tools; proficiency with Microsoft Excel, Outlook, Word, and Teams required.
• Strong organizational, analytical, communication, and follow-up skills with the ability to manage multiple priorities and confidential information.
• Overseeing 837 files daily and coordinating with IT, Delegation group, and vendor.

Mansioni

• Support the Claims Director in monitoring daily claims operations, including intake, adjudication, payment, reconciliation, aging inventory, pending claims, and high-dollar claims.
• Track, document, and help resolve escalated claims issues involving providers, IPAs, internal departments, vendors, and delegated entities.
• Maintain claims dashboards, issue trackers, reconciliation reports, audit documentation, and operational reporting for leadership review.
• Ensure processes and reports remain accurate and audit ready in line with CMS, state, health plan, and internal requirements.
• Assist with payment integrity reviews, including pricing validation, coding accuracy, authorization linkage, duplicate claim identification, and trend analysis.
• Coordinate with stakeholders to support timely issue resolution and operational alignment.
• Prepare data, reports, status updates, and materials for internal reviews, audits, and leadership meetings.
• Support claim-related projects, system implementations, testing, and process improvements.
• Coordinate communications related to claims escalations, provider inquiries, and project updates.
• Oversee daily incoming/outgoing/routing of claims in collaboration with IT and Vendor groups.
• Perform other duties to support Claims Department goals.

Conoscenze

Claims operations experience

Analytical skills

Communication skills

Familiar with CMS requirements

Team collaboration

Microsoft Excel

Microsoft Outlook

Microsoft Word

Microsoft Teams

Formazione

Bachelor's degree in business, healthcare administration, finance, public health, or related field

Strumenti

Claims systems

Excel

Outlook

Word

Teams

Descrizione del lavoro

Verda Healthcare, Inc. is a Medicare Advantage Prescription Drug Plan (MAPD) organization focused on underserved communities.

The Assistant Director, Claim Operations supports the Claims Director in daily oversight of claims processing, ensuring accuracy, timeliness, and CMS/compliance adherence. This role provides operational, administrative, analytical, and project support across dashboards, audits, and reporting, collaborating with Claims Operations, Provider Relations, Compliance, Finance,