Healthcare Claims Manager - Job Description

Position Overview
The Healthcare Claims Manager is responsible for overseeing the day-to-day operations of the claims department to ensure accurate, timely, and compliant processing of medical, dental, vision, and behavioral health claims. This role provides leadership to the claims team, ensures adherence to regulatory and organizational standards, and drives continuous improvements in efficiency, accuracy, and member experience.

Key Responsibilities

Claims Operations & Oversight

• Manage and supervise the claims processing team, including workload distribution, performance monitoring, and training.
• Oversee the review, adjudication, and resolution of healthcare claims to ensure accuracy and compliance with plan benefits, policies, and regulatory requirements.
• Identify and resolve complex claim issues, discrepancies, or escalations.
• Monitor claim turnaround times (TAT) and ensure department meets service-level standards.

Compliance & Quality Control

• Ensure claims processing complies with federal and state regulations, HIPAA guidelines, and internal policies.
• Conduct routine audits to verify accuracy and identify trends or areas for improvement.
• Develop and implement quality assurance protocols and corrective action plans when needed.

Process Improvement

• Analyze claims data to identify patterns, inefficiencies, or cost-containment opportunities.
• Recommend and implement process improvements to enhance accuracy, workflow, and productivity.
• Collaborate with IT and system vendors on claims system enhancements or updates.

Cross-Functional Collaboration

• Work closely with Member Services, Provider Relations, Finance, and Eligibility teams to support issue resolution and improve service delivery.
• Serve as a subject-matter expert on claims policies, benefits interpretation, and claims-related inquiries.
• Support leadership with reports, departmental metrics, and claims performance insights.

Team Leadership

• Provide coaching, mentorship, and development for claims staff.
• Participate in recruiting, hiring, and training new team members.
• Promote a positive, collaborative, and member-focused team culture.

Qualifications

Required

• 3-5+ years of experience in healthcare claims processing, including HMO/PPO, self-funded, or TPA environments.
• Strong knowledge of medical terminology, CPT/ICD coding, UB-04/HCFA-1500 forms, and benefit structures.
• Experience leading or supervising a team.
• Proficiency with claims processing systems and general healthcare administration workflows.
• Strong analytical and problem-solving skills with high attention to detail.

Preferred

• Experience in union benefit plans, TPAs, or health & welfare funds (if applicable).
• Familiarity with CMS, ERISA, and state regulatory requirements.
• Advanced Excel skills or experience with claims reporting tools.

Key Competencies

• Leadership & Team Development
• Analytical Thinking & Accuracy
• Claims Compliance Knowledge
• Communication & Collaboration
• Process Optimization
• Member-Centered Mindset