Remote Senior Claims Operations Leader

MediDrive, LLC; United States; On-site; USD 100,000 - 110,000; Full time

Job summary

MediDrive, LLC is seeking an experienced Senior Manager, Claims Operations to lead the end-to-end claims function and build scalable processes, controls, and reporting to support growth. You will oversee 835 ERA processing, 837 claims/encounter transactions, Medicaid reporting, and MLR analyses, partnering with Finance, Operations, Product, and Technology.

The role is hands-on and requires building a high-performance team, establishing KPIs, and driving automation across claims operations in a

Qualifications

• Bachelor's degree in healthcare administration, finance, accounting, business, information systems, or related field.
• 5+ years of healthcare claims operations experience.
• Strong hands-on experience with 835 remittance files and 837 claims/encounter transactions.
• Experience with Medicaid, managed care, health plans, TPA operations, NEMT, or another healthcare claims environment.

Responsibilities

• Lead day-to-day operation of the claims function and oversee the complete claims lifecycle from submission through adjudication, payment, denial, adjustment, and final reconciliation.
• Develop and maintain scalable claims workflows, policies, procedures, and internal controls.
• Monitor claims volumes, payment activity, outstanding claims, denials, rejections, adjustments, and exceptions.
• Identify duplicate, rejected, incorrectly processed, or unresolved claims and drive issues through resolution.
• Establish claims aging and exception-management processes to ensure outstanding items are identified and resolved timely.
• Ensure claims operations comply with applicable contractual, client, Medicaid, and regulatory requirements.
• Oversee the processing, validation, and reconciliation of 835 ERA files.
• Manage and understand 837 healthcare claims and encounter transactions, including submission, acceptance, rejection, and reconciliation.
• Oversee Medicaid encounter reporting and ensure submitted encounter data is complete, accurate, and reconciled to underlying claims and transportation activity.
• Work closely with Technology and Product teams to identify and resolve EDI, data, claims-processing, and system integration issues.
• Develop controls to ensure claims and encounter files are successfully transmitted, accepted, and appropriately reflected in downstream financial and operational systems.
• Partner with Finance and Accounting to support accurate and timely Medical Loss Ratio reporting and analysis.
• Reconcile claims and transportation expenses to client funding, provider payments, remittance activity, and financial reporting.
• Assist Finance with month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and other claims-related accounting requirements.
• Provide visibility into claims trends and cost drivers that may impact client profitability and MLR performance.
• Ensure appropriate reconciliation between operational claims systems and the General Ledger.
• Oversee claims-related processes supporting payments to transportation providers.
• Develop controls to ensure transportation providers are paid accurately and only for properly validated and approved transportation services.
• Reconcile provider payments to underlying trip and claims data.
• Partner with Finance and Operations on provider payment processes, including payments made through RAMP or similar payment platforms.
• Identify payment discrepancies, duplicate payments, missing payments, and other exceptions and ensure timely resolution.
• Develop and maintain claims dashboards, KPIs, and management reporting, including: Claims submitted, accepted, rejected, and paid; Claims aging; Denials and rejection rates; Payment turnaround times; Outstanding and unresolved claims; Encounter submission and acceptance rates; Provider payment reconciliations; MLR and claims cost trends.
• Establish measurable service levels and performance standards for the claims function.
• Provide senior management with clear visibility into claims performance, financial exposure, operational risks, and emerging trends.
• Continuously evaluate claims processes and identify opportunities for automation, improved controls, and increased efficiency.
• Serve as a key liaison between Claims, Finance, Accounting, Operations, Product, Technology, and Compliance.
• Partner with Product and Technology teams to help design and enhance MediDrive's claims technology infrastructure.
• Work directly with healthcare clients and internal stakeholders to resolve claims, encounter, reconciliation, and reporting issues.
• Support audits, client reviews, and requests for claims-related documentation.
• Help build and develop the Claims team as MediDrive's transaction volumes and client base continue to grow.

Skills

835 remittance files

837 claims/encounter

MLR reporting

Claims reconciliation

Analytics

Cross-functional collaboration

Education

Bachelor's degree in related field

Job description

MediDrive, LLC is seeking an experienced Senior Manager, Claims Operations to lead the end-to-end claims function and build scalable processes, controls, and reporting to support growth. You will oversee 835 ERA processing, 837 claims/encounter transactions, Medicaid reporting, and MLR analyses, partnering with Finance, Operations, Product, and Technology.

The role is hands-on and requires building a high-performance team, establishing KPIs, and driving automation across claims operations in a