Manager, Claims Operations

Allied Benefit Systems; United States; Remote; USD 90,000 - 130,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off

Tuition Reimbursement

EAP

Technology Stipend

Job summary

Allied Benefit Systems seeks a Manager of Claims Operations to lead the Claims Appeals, Claims Medical Review, and Subrogation teams, driving operational excellence and adherence to service level metrics. The role partners with analytics and leadership to implement best practices, review high-dollar cases, and develop staff through coaching and performance feedback while supporting remote work.

This leadership role requires strategic thinking, strong communication, and a proven track record in

Qualifications

• 5+ years of TPA or group health insurance experience including at least 3 years at a supervisor level.
• Knowledge of Claims, Benefits and administrative processes.
• Proficient with Microsoft Office suite.

Responsibilities

• Maintain collective responsibility for the management of services provided by the Claims Appeals, Claims Medical Review and Subrogation Teams.
• Monitor metrics and operations within these teams.
• Identify strategic opportunities based on financial analysis and projections, cost/benefit identification.
• Provide support, guidance, leadership, and motivation to promote maximum performance.
• Prepare reporting and analysis consistent with defined standards and processes.
• Provide technical guidance to staff on claim investigation, reserving evaluation and resolution of claims.
• Collaborate with analytical team to produce results and trending reports for leadership.
• Review high-dollar appeals, medical review referrals, and subrogation cases from members, providers, and other entities.
• Manage all aspects of the day-to-day operations of claims production.
• Interact extensively with various parties involved in the claim process.
• Remain current on impact on claims management strategies.
• Collaborate with other Claims and business leaders to drive enterprise initiatives.
• Assist or prepare files for subrogation.
• Create an environment that encourages the sharing of information and ideas.
• Oversee monitoring and tracking of performance against productivity and quality goals and metrics.
• Lead, coach, motivate and develop staff; conduct performance appraisals and growth opportunities.
• Communicate expectations and provide training, resources, and information needed to succeed.
• Engage, coach, counsel and provide timely performance feedback.
• Other duties as assigned

Skills

Leadership

Communication

Project management

Business writing

Education

Bachelor’s degree or equivalent work experience

Tools

Microsoft Office

Excel

PowerPoint

Access

Job description

POSITION SUMMARY

The Manager, Claims Operations is responsible for managing the day-to-day operational functions of the Claims Appeals, Claims Medical Review, and Subrogation Teams.

ESSENTIAL FUNCTIONS

• - Maintains collective responsibility for the management of services provided by the Claims Appeals, Claims Medical Review and Subrogation Teams. Additionally, responsible for monitoring metrics and operations within these teams
• - Responsible for implementing best practices based on company goals
• - Identify strategic opportunities based on financial analysis and projections, cost/benefit identification and analysis
• - Provide support, guidance, leadership, and motivation to promote maximum performance
• - Responsible for preparing reporting and analysis that is consistent with defined standards and processes
• - Provide technical guidance to staff on claim investigation, reserving evaluation and resolution of claims
• - Partner with analytical team to produce necessary results and trending reports for leadership
• - Review high dollar appeals, medical review referrals, and subrogation cases from members, providers, and other entities
• - Manage all aspects of the day-to-day operations of claims production
• - Interact extensively with various parties involved in the claim process
• - Remain current and aware of impact on claims management strategies
• - Collaborate with other Claims and business leaders to define and drive enterprise initiatives
• - Assist or prepare files for subrogation
• - Create an environment that encourages and values the opinions of others and promotes sharing of information and ideas
• - Oversee monitoring and tracking of individuals and the unit's performance against established productivity and quality goals and metrics.
• - Lead, coach, motivate and develop. Responsible for one-on-one meetings, performance appraisals, growth opportunities and attracting new talent
• - Clearly communicate expectations , provide employees with the training, resources, and information needed to succeed
• - Actively engage, coach, counsel and provide timely, and constructive performance feedback
• - Other duties as assigned

EDUCATION

• - Bachelor’s degree or equivalent work experience required

EXPERIENCE AND SKILLS

• - At least 5 years of TPA or group health insurance experience including at least 3 years at a supervisor level and successfully demonstrated leadership competencies
• - In-depth knowledge of Claims, Benefits and administrative skills and processes required.
• - Intermediate level work experience with Microsoft Office, Word, Excel, Access, and Power Point software applications
• - The ability to easily learn other software and systems
• - Must be able to write business correspondence and procedures

POSITION COMPETENCIES

• - Accountability
• - Coaching and Feedback
• - Collaboration
• - Customer Focus
• - Decision Making
• - Execution Management
• - People Leadership

PHYSICAL DEMANDS

• - This is a standard desk job requiring extended sitting and computer work.

WORK ENVIRONMENT

• - Remote

Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive .

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.

Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.