Hospital Claims Operations Manager (Hybrid)

1199SEIU Benefit and Pension Funds; New York (NY); Hybrid; USD 90,000 - 130,000; Full time

Job summary

1199SEIU Benefit and Pension Funds in New York, NY, seeks an experienced Hospital Claims Department Leader to oversee the Processor and Clerical Unit. You will manage workflows, supervise staff, and ensure accurate processing of hospital claims, SPD-compliant documentation, and referrals across COB and pre-authorization rules.

You will collaborate with Care Management, Provider Relations, IT, and third-party vendors, drive process improvements, mentor staff, and ensure HIPAA and internal

Qualifications

• Bachelor's degree or equivalent years of work experience.
• Minimum of five (5) years hospital claims processing, quality assurance, auditing experience; at least two (2) years in a supervisory role.
• Strong knowledge of CPT, ICD-10, HCPCS, UB-04 and hospital reimbursement methodologies; solid contract understanding.
• Knowledge of eligibility, medical terminology, COB and third-party reimbursement.
• Proficient in Word and Excel; able to manage data and generate reports.

Responsibilities

• Responsible for day-to-day operations of Hospital Claims Department in the Processor and Clerical Unit.
• Provide direction and support to Assistant Manager and Supervisors; optimize workflows and monitor performance.
• Ensure timely and accurate processing of hospital claims, correspondence, and Call Tracking tickets per SPD guidelines and COB requirements.
• Manage staff per HR guidelines and CBA provisions; review performance and QA audit results; coordinate training.
• Monitor QNXT reports and DMS/Call Tracking systems; resolve escalated issues; release high-dollar claims.
• Develop policies and procedures; pursue continuous process improvements; coordinate with Care Management and IT to resolve issues.
• Oversee testing related to QNXT upgrades and external vendor processes; backup for Assistant Director and Unit Manager when needed.
• Prepare attendance/late records; approve payroll; participate in vendor calls and Joint Operating Committee meetings.

Skills

Leadership

Analytical skills

Communication skills

Time management

Education

Bachelor's degree or equivalent

Tools

Microsoft Word

Microsoft Excel

Job description

1199SEIU Benefit and Pension Funds in New York, NY, seeks an experienced Hospital Claims Department Leader to oversee the Processor and Clerical Unit. You will manage workflows, supervise staff, and ensure accurate processing of hospital claims, SPD-compliant documentation, and referrals across COB and pre-authorization rules.

You will collaborate with Care Management, Provider Relations, IT, and third-party vendors, drive process improvements, mentor staff, and ensure HIPAA and internal