Remote Program Manager - Health Plan Claims

SCAN Group; Long Beach (CA); Remote; USD 106,000 - 154,000; Full time

Benefits offered by this job

Bonus program

Wellness program

PTO

Holidays

401(k) match

Recognition program

Tuition reimbursement

Mostly Remote Work Mode

Job summary

SCAN is seeking a Program Manager - Claims to lead escalations, provider relations, pricing interpretation, and complex claims resolution for AEP/OEP. You will collaborate with internal teams and external partners to ensure compliant adjudication and data-driven improvements.

The role supports Total Cost of Care initiatives, staffing plans, and system enhancements, while reporting to senior leadership. A strong background in healthcare claims and cross-functional program management is required;

Qualifications

• Bachelor's degree or equivalent in Business Administration, Healthcare Administration, Finance, or a related field.
• 2–3 years of leadership experience.
• 5+ years of progressive experience in healthcare claims operations.
• 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 improvements.
• 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.
• Excellent written and verbal communication; independent judgment.
• Leadership and problem-solving abilities; process optimization.
• Advanced Microsoft Office Suite, Visio, and SQL experience.

Responsibilities

• Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation.
• Investigate and resolve complex, high-dollar claims and ensure claims are adjudicated according to policies, contracts, and regulatory requirements.
• Work with providers, members, Medical Management, Coding, Billing, and Finance to resolve claims issues.
• Analyze claims and operational data to identify trends, operational problems, cost savings, and process improvement opportunities.
• Collaborate with Network Management and work directly with external partners, as needed, to address claims-related issues.
• Lead claims triage and management for the Annual Enrollment Period and Open Enrollment Period (AEP/OEP).
• Support Total Cost of Care initiatives by identifying and implementing opportunities to improve efficiencies.
• Support staffing plans and resource allocation for claims programs and initiatives.
• Manage vendor or third-party claims relationships, when applicable.
• Support system implementations and claims-platform upgrades, including leading testing and workflow changes, and partner with senior leadership to develop resolution solutions for escalated cases.
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN's Vision and Goals.
• Other duties as assigned.

Skills

Leadership experience

Cross-functional collaboration

Claims operations

Data analysis

Project management

Communication skills

SQL

MS Office

Visio

Education

Bachelor's Degree in Business Administration or related field

Tools

Visio

Microsoft Office

Job description

SCAN is seeking a Program Manager - Claims to lead escalations, provider relations, pricing interpretation, and complex claims resolution for AEP/OEP. You will collaborate with internal teams and external partners to ensure compliant adjudication and data-driven improvements.

The role supports Total Cost of Care initiatives, staffing plans, and system enhancements, while reporting to senior leadership. A strong background in healthcare claims and cross-functional program management is required;