Remote Senior Claims Program Manager, Health Plan

SCAN; United States; Teletrabalho; USD 106 000 - 154 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Remote work

Annual bonus

Wellness program

PTO

Holidays

401(k)

Recognition program

Tuition reimbursement

Resumo da oferta

SCAN is seeking a Program Manager - Claims to lead complex, high-dollar claims operations across multiple states. You will drive triage, policy interpretation, and cross-functional collaboration to resolve escalations and improve cost efficiency.

Candidates bring 5+ years in healthcare claims, strong leadership, and expert knowledge of Medicaid/Medicare policies, with a track record in process improvement and data-driven decision making.

Qualificações

• Bachelor's degree or equivalent in business administration, healthcare administration, finance, or related field.
• 2–3 years of leadership experience.
• 5+ years of progressive healthcare claims operations or related health plan function.
• Experience managing cross-functional programs, complex claims issues, or vendor initiatives.
• Experience with Medicare Advantage claims operations and regulatory requirements preferred.
• Strong knowledge of claims adjudication, policies, contracts, and regulatory requirements.
• Ability to interpret NCD/LCD and other payment policies.
• Strong written and verbal communication skills; ability to present to senior leadership.
• Ability to work independently and manage sensitive escalated matters.
• Advanced Microsoft Office, Visio, and SQL experience.

Responsabilidades

• Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation.
• Investigate and resolve complex, high-dollar claims in accordance with policies and regulatory requirements.
• Collaborate with providers, members, Medical Management, Coding, Billing, and Finance to resolve claims issues.
• Analyze claims and operational data to identify trends and cost-saving opportunities.
• Lead claims triage and management for AEP/OEP periods.
• Support Total Cost of Care initiatives and staffing/resource allocation for claims programs.
• Manage vendor or third-party claims relationships when applicable.
• Support system implementations and claims-platform upgrades, including testing and workflow changes.

Conhecimentos

Leadership

Healthcare claims

Cross-functional programs

Communication

Problem solving

Project management

Staffing planning

Formação académica

Bachelor's Degree

Ferramentas

Microsoft Office Suite

Visio

SQL

Descrição da oferta de emprego

SCAN is seeking a Program Manager - Claims to lead complex, high-dollar claims operations across multiple states. You will drive triage, policy interpretation, and cross-functional collaboration to resolve escalations and improve cost efficiency.

Candidates bring 5+ years in healthcare claims, strong leadership, and expert knowledge of Medicaid/Medicare policies, with a track record in process improvement and data-driven decision making.