Medicare Claims Operations Leader

Zing Health Holdings Inc; Alton (IL); On-site; USD 95,000 - 140,000; Full time

Job summary

Zing Health Holdings Inc. is seeking a seasoned leader to oversee Medicare claims operations. You will ensure CMS compliance, manage claims production, vendor oversight, and internal controls, and drive improvements across MA Plan contracts.

The role requires strong supervision, regulatory knowledge, and cross-functional collaboration to maintain accurate reporting and timely provider interactions. Responsibilities include monitoring performance, coordinating with QA, and guiding staff through

Qualifications

• Four years minimum in a manager level role or above
• Four years of Medicare claims experience required
• Seven years of health plan administration experience

Responsibilities

• Oversee claims production and vendor oversight for Medicare Advantage line of business
• Establish, implement, and provide improvements to internal controls and department policies and procedures
• Maintains knowledge of government regulations as it pertains to claims payments and recognized claims processing standards
• Investigates and responds to letters of inquiry on claims from members, providers, networks, and government agencies
• Ensure adequate quality controls and participate with support departments to analyze the root cause of claim payment variations
• Ensure claim support services achieve high provider satisfaction and timely dispute/appeal responsiveness
• Interact with Core Configuration team and vendors to ensure claims systems are robust, compliant and supports business developmental needs
• Helps to coordinate the implementation and maintenance of electronic data interchange (EDI) related to claims submissions and processing status
• Works diligently to ensure accurate claims payment and associated documentation (remits). Identifies trend and resolutions to reduce provider disputes.
• Monitors staff's work regularly for quality and efficiency. Provides training, feedback, coaching, and disciplinary action to staff, if necessary. Supports staff in meeting standards, solving problems, and enhancing performance.
• Works collaboratively with other departments to resolve issues efficiently. Identifies and communicates problems to senior leadership timely.
• Provides support and guidance to Medicare operations to ensure operations are compliant with MA Plan contractual requirements and CMS regulations.
• Monitors day-to-day performance and provide reports to MRx Compliance as required. Participates in ongoing operational and compliance audits. Ensure that reporting is accurate and complete.
• Participates in the planning, development and implementation of new accounts, programs, products and services, initiates and develops short- and long-range plans for department and participates in the development of corporate and strategic plans.
• Participates in implementation of Corrective Action Plans (CAPS).
• Assists Quality Improvement efforts in quarterly audits.

Job description

Zing Health Holdings Inc. is seeking a seasoned leader to oversee Medicare claims operations. You will ensure CMS compliance, manage claims production, vendor oversight, and internal controls, and drive improvements across MA Plan contracts.

The role requires strong supervision, regulatory knowledge, and cross-functional collaboration to maintain accurate reporting and timely provider interactions. Responsibilities include monitoring performance, coordinating with QA, and guiding staff through