Sr Manager, Claims

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Sr. Manager, Claims is accountable for the performance of Claims production team. This role requires strong leadership and the ability to manage a team of claims professionals while collaborating with internal and external stakeholders. The Senior Claims Manager will also be responsible for ensuring that claims are handled in compliance with company policies, regulatory requirements, and industry standards. The Sr. Man-ager works with other operational areas to improve claims processing accuracy and gain operational efficiencies. Plays a key role in training, problem resolution, workflow optimization and process improvement.

Job Duties/Responsibilities:

1. Manage daily operations, including the management of claims inventory, production, and processing timelines, ensuring efficiency and accuracy.

2. Ensure consistent adherence to compliance standards across all operational functions.

3. Proactively address and resolve any issues or challenges arising within daily operations

4. Collaborate effectively with cross-functional teams to enhance claims payment accuracy and streamline processes.

5. Address provider concerns promptly and accurately, ensuring timely resolution.

6. Develop, implement, and maintain comprehensive policies and procedures, as well as training programs related to claims processing and payment.

7. Identify operational gaps or inefficiencies, determine root causes, and implement corrective actions to resolve them.

8. Assess and allocate resources necessary for change initiatives, taking into account a broad range of considerations when making decisions.

9. Communicate processing changes clearly to all relevant stakeholders, including internal teams and external vendors, ensuring alignment and understanding.

10. Utilize available resources effectively to meet key performance metrics and operational goals.

11. Partner with Data Operations or relevant stakeholders to design and maintain accurate claims reports and performance dashboards.

12. Oversight of claims administrative vendors, ensuring service level agreements are consistently met.

13. Keep administrative vendors informed of organizational changes or updates, ensuring service levels are adjusted in accordance with evolving business needs.

14. Foster a positive and productive work environment, driving team engagement and morale.

15. Lead and motivate a high-performance team through effective recruitment, onboarding, training, and retention strategies.

Supervisory Requirements:

Fulfill supervisory responsibilities in accordance with organization policies and applicable laws.  Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems

Job Requirements:

Experience:

• Required: 5 years claims management experience preferably in Medicare Managed Care or health plan setting

Education:

• Required: High School Diploma or GED.

• Preferred: Bachelor's degree

Specialized Skills:

• Required:

• Comprehensive knowledge of Medicare Advantage claims processing requirements, CMS reporting requirements and other related regulatory requirements
• Extensive knowledge of different payment methodologies (PPS, Medicare fee schedules, etc.), claims coding and billing requirements
• Claims processing system experience, Facets experience a plus
• Proficiency in Microsoft programs including at least intermediate proficiency with Excel, Word and PowerPoint
• Ability to effectively communicate and work with multiple levels of personnel both verbal and written
• Detail oriented and ability to multi-task and able to meet frequently changing work demands
• Strong leadership skills with the ability to mentor direct reports and develop teams.
• Strong organizational skills and decision-making and attention to details
• Ability to work well in a fast-paced and dynamic environment.

Licensure:

• Required: None

• Preferred:

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $98,550.00 - $147,825.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.

Salary : $98,550 - $147,825