Remote Claims Program Manager – Health Plan

SCAN Group; United States; Remote; USD 106,000 - 154,000; Full time

Benefits offered by this job

Annual bonus

Wellness program

PTO

Holidays

401(k) match

Tuition reimbursement

Job summary

SCAN is seeking a Program Manager - Claims to lead escalations, provider relations, and complex claims management. You will collaborate with Medical Management, Coding, Billing, and Finance to resolve issues and drive cost-saving improvements.

The role supports AEP/OEP triage, Total Cost of Care initiatives, and staffing/resource planning. Strong communication and leadership are essential for success.

Qualifications

• Bachelor's Degree or equivalent in Business Administration, Healthcare Administration, Finance, or related field.
• 5+ years of progressive healthcare claims experience and 2–3 years of leadership experience.
• Experience managing cross-functional programs, vendors, or claims-related initiatives.
• Experience with Medicare Advantage claims operations and regulatory requirements preferred.
• Ability to interpret NCD/LCD and other payment policies.
• Strong analytical skills to identify trends, cost savings, and process improvements.
• Strong written and verbal communication skills for senior leadership.
• Ability to work independently and manage sensitive/escalated matters.

Responsibilities

• Manage claims escalations, provider abrasion, service issues, pricing, and payment policy interpretation.
• Investigate and resolve complex, high-dollar claims ensuring adjudication per policies and regulations.
• Collaborate with providers, members, Medical Management, Coding, Billing, and Finance on claims issues.
• Analyze claims data to identify trends and opportunities for cost savings and process improvements.
• Lead claims triage and management for AEP/OEP periods.
• Support Total Cost of Care initiatives by identifying efficiency opportunities.
• Support staffing plans and resource allocation for claims programs.
• Manage vendor or third-party claims relationships when applicable.

Skills

Leadership

Problem solving

Process optimization

Communication

Microsoft Office

Visio

Cross-functional collaboration

Education

Bachelor's Degree or equivalent

Tools

SQL

Job description

SCAN is seeking a Program Manager - Claims to lead escalations, provider relations, and complex claims management. You will collaborate with Medical Management, Coding, Billing, and Finance to resolve issues and drive cost-saving improvements.

The role supports AEP/OEP triage, Total Cost of Care initiatives, and staffing/resource planning. Strong communication and leadership are essential for success.