Remote Claims Program Manager - Health Plan

SHPCA SCAN Health Plan; City of Long Beach (NY); Remote; USD 106,000 - 154,000; Full time

Benefits offered by this job

Mostly Remote

Annual bonus program

Wellness program

Paid time off

Job summary

SCAN Health Plan is seeking a Program Manager - Claims to lead complex escalated claims, pricing interpretations, and provider issues. You will collaborate with Finance, Coding, Medical Management, and Network teams to resolve cases while aligning with regulatory requirements.

The role emphasizes data analysis, cost-saving initiatives, and support for AEP/OEP periods. The position offers mostly remote work, opportunities for impact with a national footprint, and advancement within a

Qualifications

• Bachelor's degree or equivalent in Business Administration, Healthcare Administration, Finance, or related field; or equivalent experience.
• 2-3 years of leadership experience.
• 5+ years of progressive experience in healthcare claims operations or related health plan function.
• Experience managing cross-functional programs, complex claims issues, vendors, or initiatives.
• Experience with Medicare Advantage claims operations and regulatory requirements preferred.
• Strong knowledge of claims adjudication, operations, pricing, and applicable policies, contracts, and regulatory requirements.
• Ability to interpret NCD/LCD and other payment policies.
• Demonstrated ability to investigate and resolve complex, high-dollar, escalated claims.
• Strong analytical skills to identify trends, problems, and cost-saving opportunities.
• Ability to collaborate with providers, members, Medical Management, Coding, Billing, Finance, Network Management, vendors, and external partners.
• Program and project management skills to lead multiple priorities and deliver results.
• Ability to support staffing plans and resource allocation.
• Experience supporting system implementations and claims-platform upgrades; testing and workflow changes.
• Strong written and verbal communication skills for senior leadership.

Responsibilities

• Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation.
• Investigate and resolve complex, high-dollar claims following policies, contracts, and regulatory requirements.
• Collaborate with providers, members, Medical Management, Coding, Billing, Finance, Network Management, vendors, and external partners to resolve issues.
• Analyze claims and data to identify trends, operational problems, and cost-saving opportunities.
• Lead claims triage and management for AEP/OEP; support Total Cost of Care initiatives and staffing/resource plans.

Skills

Leadership experience

Healthcare claims operations

Data analysis

Cross-functional programs

NCD/LCD interpretation

Vendor management

SQL experience

Microsoft Office

Education

Bachelor's degree or equivalent

Tools

SQL

Microsoft Office

Visio

Job description

SCAN Health Plan is seeking a Program Manager - Claims to lead complex escalated claims, pricing interpretations, and provider issues. You will collaborate with Finance, Coding, Medical Management, and Network teams to resolve cases while aligning with regulatory requirements.

The role emphasizes data analysis, cost-saving initiatives, and support for AEP/OEP periods. The position offers mostly remote work, opportunities for impact with a national footprint, and advancement within a