Claims Operations Manager

LINECO; Lombard (IL); On-site; USD 105,000 - 140,000; Full time

Benefits offered by this job

Employer-funded health plan

Job summary

LINE Construction Benefit Fund (LINECO) seeks a highly organized Claims System Manager to oversee the architecture of IBM systems and SaaS-based claims adjudication software for medical and dental benefits.

The role collaborates with the Claims Processing Department to set strategic direction for daily claims administration, electronic workflows, and benefit templates, ensuring accuracy and efficiency across programs.

Qualifications

• Bachelor’s degree or 5+ years’ independent work in health insurance/payor role.
• 3 years project management on large multi-million-dollar healthcare projects.
• Strong communication with senior management across departments.
• Experience researching issues using databases/systems.

Responsibilities

• Track project progress, milestones, issues, and reporting.
• Develop and maintain an audit tool for group setup and go-live processes.
• Evaluate projects for quality assurance and cost-effectiveness.
• Create process flows to streamline workflows and SOPs.
• Organize and participate in meetings to foster a shared approach.

Skills

Project management

Communication

Analytical thinking

EDI & claims processing

Software integration

Education

Bachelor's degree or equivalent healthcare/payor experience

5+ years independent work in health insurance/payor role

Tools

Access

Excel

Word

PowerPoint

IBM applications

Job description

The Line Construction Benefit Fund, commonly known as LINECO, was founded in 1963 and is a self-funded, self-administered health and welfare plan that provides a comprehensive suite of benefits to IBEW and NECA members working in the outside electrical construction industry. LINECO offers a full range of medical benefits, including prescription drug coverage, dental benefits, vision, short term disability, life insurance, and behavioral health support designed to provide members with the best care available at a predictable cost.

LINECO seeks an organized, knowledgeable, and detail-oriented Claims System Manager. Job responsibilities include understanding the architecture of multiple IBM systems and claims adjudication software (SaaS) that support the payment of medical and dental claims on behalf of our essential members. The role will involve working closely with the medical and dental Claims Processing Department and developing best practices and strategic direction for daily claims administration, electronic workflows, and benefit templates.

Essential Duties and Responsibilities:

• Track project progress and updates, and monitor deliverables, milestones, and issues for accurate reporting.
• Develop and maintain an audit tool for multiple groups to identify errors within group set-up and go-live processes for specific products.
• Evaluate internal projects for quality assurance and cost-effectiveness, ultimately helping SME’s select the best data to share for project success with PBMs and other vendors.
• Create process flows to help streamline workflows and layout proper process channels for internal standard operating procedures.
• Organize and participate in meetings and workshops to foster a shared project approach.

Required Qualifications:

• Bachelor’s degree in related field OR at least 5 years’ experience involving independent work and judgment in a health insurance or healthcare payor role
• 3 years project management experience with large and complex multi-million-dollar projects in healthcare or pharmacy benefits
• Strong communication and technical skills and a willingness to work with senior management from multiple departments
• Experience researching issues and conducting research using databases/systems

Strong analytical prowess in regression testing and claims processing outcomes

• Strong understanding of coding complex employee benefits transactions into a claims adjudication system
• Strong understanding of EDI compliant transactions such as EDI 837 and 835 file layouts and resolutions
• Ability to learn current protocol quickly and infuse past experiences into new systems
• Experience managing multiple complex projects successfully
• Strong organizational skills and detail-oriented
• PC proficiency to include Access, Excel, Word and PowerPoint. Important to also deal with various IBM applications

Preferred Qualifications:

• Lead, consultant, or supervisory experience within medical/dental claims payor organization. Additional experience administering HRA Plans and familiarity with Medicare (CMS) payment protocols is helpful
• Experience with file creation, exchange, and data-testing protocols
• Experience supervising project teams and personnel
• Experience with or knowledge of BlueCross BlueShield Inter-Plan Teleprocessing System (ITS) a.k.a., BlueCard
• Past experience processing medical/dental claims
• Experience working in a Taft-Hartley, union, or multiemployer benefit fund environment
• Familiarity with ERISA, HIPAA, and self-funded health plans

You’ll love working with us because…

• We are a hard-working, mission-driven organization who prides ourselves on providing best-in-class service to our members.
• We are people-centric. Our team consists of employees with long tenures, and we foster engagement and appreciation with our employees.
• We are humble, compassionate, and empathetic and let this guide our mission and values.
• You will have the ability to quickly influence positive change in the US healthcare system.
• We have a fun and engaging culture driven by our employee experience committee with planned monthly activities.

We offer a competitive annual salary with an exceptional health and welfare benefits package that is 100% employer-funded and includes:

• Medical, Dental, Vision, and Prescription Drug insurance
• Health Reimbursement Account
• Defined Contribution Pension Plan (100% employer-funded)
• Annuity Plan (100% employer-funded)
• Comprehensive time-off plan that includes generous vacation/sick/personal time (PLAWA)
• Referral and spot bonus when applicable

LINECO is an Equal Opportunity Employment/Affirmative Action employer dedicated to providing an inclusive workplace where the unique differences of our employees are welcomed, respected, and valued.

RECRUITER NOTE: This role is being recruited on behalf of LINECO; all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.