Senior Medicare Claims Operations Lead

Zing Health, Inc.; Illinois; On-site; USD 90,000 - 120,000; Full time

Job summary

Zing Health, Inc. is seeking an experienced Manager to lead Medicare claims operations across the company, ensuring CMS compliance and accurate reporting.

The role oversees claims production, vendor oversight, and internal controls, coordinating with cross-functional teams to support CAPs and audits. The position requires strong knowledge of CMS regulations and prior Medicare claims experience, along with leadership and process-improvement skills to drive performance and compliance.

Qualifications

• Four (4) years minimum in a manager level role or above.
• Four (4) years of Medicare claims experience required, and Medicare/DSNP/ACA Exchange operations experience preferred.
• Seven (7) years of health plan administration experience.

Responsibilities

• Oversee claims production and vendor oversight for Medicare Advantage line of business.
• Establish, implement, and provide improvements to internal controls and department policies and procedures.
• Maintains knowledge of government regulations as it pertains to claims payments and recognized claims processing standards.
• Investigates and responds to letters of inquiry on claims from members, providers, networks, and government agencies.
• Ensure adequate quality controls and participate with support departments to analyze the root cause of claim payment variations.
• Ensure claim support services achieve high provider satisfaction and timely dispute/appeal responsiveness.
• Interact with Core Configuration team and vendors to ensure claims systems are robust, compliant and supports business developmental needs.
• Helps to coordinate the implementation and maintenance of electronic data interchange (EDI) related to claims submissions and processing status.
• Works diligently to ensure accurate claims payment and associated documentation (remits). Identifies trends and resolutions to reduce provider disputes.
• Monitors staff's work regularly for quality and efficiency. Provides training, feedback, coaching, and disciplinary action to staff, if necessary. Supports staff in meeting standards, solving problems, and enhancing performance.
• Works collaboratively with other departments to resolve issues efficiently. Identifies and communicates problems to senior leadership timely.
• Provides support and guidance to Medicare operations to ensure operations are compliant with MA Plan contractual requirements and CMS regulations.
• Monitors day-to-day performance and provide reports to MRx Compliance as required. Participates in ongoing operational and compliance audits. Ensure that reporting is accurate and complete.
• Participates in the planning, development and implementation of new accounts, programs, products and services, initiates and develops short- and long-range plans for department and participates in the development of corporate and strategic plans.
• Participates in implementation of Corrective Action Plans (CAPS).
• Assists Quality Improvement efforts in quarterly audits.

Skills

Claims processing

CMS regulations

Quality control

Training & coaching

Cross-functional collaboration

Tools

EDI software

Job description

Zing Health, Inc. is seeking an experienced Manager to lead Medicare claims operations across the company, ensuring CMS compliance and accurate reporting.

The role oversees claims production, vendor oversight, and internal controls, coordinating with cross-functional teams to support CAPs and audits. The position requires strong knowledge of CMS regulations and prior Medicare claims experience, along with leadership and process-improvement skills to drive performance and compliance.