Claims Operations Manager – Medicare Advantage / ISNP
Alpharetta, GA
Full Time
Mid Level
Position Summary:
The Claims Operations Manager will oversee daily claims processing activities and drive operational efficiency in alignment with CMS and state regulatory requirements. The ideal candidate will have strong experience in Medicare Advantage and Institutional Special Needs Plans (ISNP), a deep understanding of claims adjudication processes, and familiarity with Plexis or similar claims systems.
Key Responsibilities:
Qualifications:
The Claims Operations Manager will oversee daily claims processing activities and drive operational efficiency in alignment with CMS and state regulatory requirements. The ideal candidate will have strong experience in Medicare Advantage and Institutional Special Needs Plans (ISNP), a deep understanding of claims adjudication processes, and familiarity with Plexis or similar claims systems.
Key Responsibilities:
- Manage and oversee daily claims processing operations, ensuring compliance with CMS and state regulations.
- Lead, train, and mentor claims staff to achieve departmental goals and maintain quality standards.
- Develop and implement process improvements to enhance claims accuracy and turnaround times.
- Collaborate with cross-functional teams (Provider Relations, Finance, Utilization Management, and IT) to resolve claims issues.
- Conduct audits and root cause analyses to identify trends and prevent future errors.
- Monitor performance metrics and generate reports for leadership review.
- Serve as Subject Matter Expert (SME) on ISNP and Medicare Advantage claims processing.
- Participate in system testing, configuration, and enhancements related to Plexis or other claims platforms.
- Support compliance initiatives and maintain documentation for audits and corrective actions.
Qualifications:
- Bachelor’s degree in Business, Healthcare Administration, or related field (or equivalent experience).
- Minimum 5 years of experience in claims management within a managed care or health plan environment.
- In-depth knowledge of Medicare Advantage and ISNP regulations and operations.
- Strong understanding of CMS guidelines, encounter data submissions, and claims audits.
- Experience with Plexis or other claims processing platforms preferred.
- Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint).
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