Claims Team Manager

About the Company

A well-established Health Administration company with over five decades of industry experience is looking to hire a Claims Manager. Based in Katy, Texas, close to Highway 99 and Westpark Tollway, the organization has been delivering exceptional services to its clients since 1970, maintaining a leadership position in the sector.

Role Overview

The Claims Manager will oversee the Claims Department's overall function, coordinating with various departments such as IT, Account Management, Stop Loss, Customer Service, Medical Help Line, and Sales. The role demands ensuring claims are processed accurately and in a timely manner while delivering superior client service.

Key Responsibilities

• Provide strong leadership by mentoring, coaching, and managing the Claims team effectively.
• Direct claims operations that include management of High Dollar Claims, Plan Build, ID Cards, Provider setup, and VBA testing activities.
• Strategize to increase the proportion of auto-adjudicated claims to 50%.
• Track and maintain productivity, quality standards, and turnaround times, targeting 100% of claims processed within 30 days and 90% within 14 days.
• Analyze performance trends and implement solutions to address and improve these areas.
• Supervise claims inventories, handle workflows, and manage exceptions efficiently.
• Address complex or escalated claims to prevent recurrence of issues.
• Ensure adherence to company policies, contractual obligations, and audit compliance.
• Recommend enhancements in workflows, policies, and procedures to improve efficiency.
• Lead training initiatives, cross-training sessions, and onboarding activities in coordination with Human Resources.
• Prepare and communicate management reports that highlight operational trends, risks, and strategic suggestions.
• Collaborate with Sales and Account Management teams to facilitate smooth implementations for new clients and renewal processes.

Candidate Requirements

• Minimum of 5 years in supervisory roles and at least 3 years in management within the group health claims sector.
• Comprehensive understanding of commercial health insurance products such as HMO, PPO, EPO, HDHP, and HRA/HSA plans.
• Proficient knowledge of claims adjudication processes, eligibility criteria, and benefit assessments.
• Experience engaging with stop loss carriers and managing direct agreements with providers.
• Familiarity with medical coding systems including CPT and ICD-10.
• Exceptional leadership abilities coupled with strong communication and team development skills.
• Capacity to perform effectively in a dynamic, fast-paced volume-driven environment.
• Advanced skills in organizational design and workflow optimization.
• Proficiency in Microsoft Office applications; knowledge of VBA programming is advantageous.

Why Work With Us?

• Join a stable and reputable company with a longstanding industry presence.
• Experience a collaborative working atmosphere with exposure to cross-functional leadership.
• Play a significant role in influencing operational effectiveness and company growth.