Remote Senior Manager, Medical & Claims Policy

brightonhealthplansolutions; Chapel Hill (NC); On-site; USD 120,000 - 170,000; Full time

Benefits offered by this job

Remote work

Job summary

Brighton Health Plan Solutions, LLC is seeking a Senior Manager of Medical and Clinical Claim Policy and Configuration to lead policy content and system configurations. You will work closely with Medical Management, Network Management, Claims, IT, Sales, Legal, and Operations to implement effective policies.

The role offers remote work and requires deep expertise in medical claims policy, CPT/HCPCS/ICD coding, and regulatory alignment. Strong collaboration and analytical skills are essential.

Qualifications

• Expert understanding of Medical Claims operations including medical policy, claims policy, quality assurance, utilization review, and medical cost management.
• Solid understanding of claim processing including pricing and code editing.
• Strong organizational and planning skills to manage multiple priorities and meet deadlines.
• Experience with CPT/HCPCS/ICD coding references and CMS policies.

Responsibilities

• Review, update, evaluate and develop medical and clinical claims policies for Commercial medical insurance to promote quality, optimize utilization and cost effectiveness.
• Collaborate with multiple departments to implement policies for effective management of medical expenses and quality care.
• Develop and maintain Prior Authorization lists for Commercial business.
• Manage policy web content and publication; lead CES rule/configuration initiatives.
• Prepare analyses and recommendations for policy updates and new code implementations for Medical Director review.
• Digitize and maintain medical policies, configure content in systems, ensure version control and regulatory alignment.
• Maintain JIVA automation code sets, rules, and configurations to support claims processing and utilization management.
• Work with Benefits team and High Dollar team for client configurations and questions.

Skills

Medical claims operations

Policy interpretation

Communication skills

Analytical thinking

Regulatory familiarity

Education

Bachelor's degree in healthcare or health policy

Advanced degree preferred

Tools

Microsoft Word

Excel

Job description

Brighton Health Plan Solutions, LLC is seeking a Senior Manager of Medical and Clinical Claim Policy and Configuration to lead policy content and system configurations. You will work closely with Medical Management, Network Management, Claims, IT, Sales, Legal, and Operations to implement effective policies.

The role offers remote work and requires deep expertise in medical claims policy, CPT/HCPCS/ICD coding, and regulatory alignment. Strong collaboration and analytical skills are essential.