TPA Claims Manager

Job Summary

Vault Strategies is seeking a Claims Manager to oversee and manage the claims processing function within our Third-Party Administrator (TPA) services. This role ensures accurate and efficient adjudication of medical, dental, and ancillary insurance claims across various funding structures, including self-funded, level-funded, small employers, and MEC/MVP plans. The Claims Manager will lead a team of claims processors, enforce compliance with regulatory requirements, develop and implement an escalated claims resolution process, and drive process improvements to enhance operational efficiency.

Key Responsibilities

Claims Processing & Adjudication

• Oversee the end-to-end claims adjudication process, ensuring compliance with plan documents, stop-loss carrier guidelines, and regulatory requirements (ERISA, ACA, HIPAA).
• Monitor claim accuracy, timeliness, and performance metrics, ensuring service-level agreements (SLAs) are met.
• Investigate and resolve complex or escalated claims, including eligibility disputes, medical necessity determinations, coding discrepancies, and provider payment issues.
• Work with stop-loss carriers to coordinate high-dollar claims reimbursement and proper attachment point tracking.
• Develop and implement a standardized escalated claims resolution process to ensure timely investigation and resolution of high-priority claim disputes and minimize disruptions for employer groups, providers, and members.

Compliance & Regulatory Oversight

• Ensure claims processing adheres to all state and federal regulations, including ACA, ERISA, and CMS guidelines.
• Stay updated on regulatory changes and implement necessary updates to claims processes and adjudication rules.
• Coordinate with legal and compliance teams to address regulatory audits, appeals, and reporting requirements.

Process Optimization & System Enhancements

• Partner with IT and claims system vendors to optimize adjudication software functionality (e.g., automation, fraud detection, and reporting tools).
• Identify inefficiencies in claims workflows and recommend process improvements to reduce errors, improve turnaround time, and enhance cost containment strategies.
• Collaborate with data analytics teams to develop claims insights, fraud detection models, and cost-containment initiatives.

Team Leadership & Training

• Manage and mentor a team of claims processors, providing training and performance feedback.
• Develop standard operating procedures (SOPs) and training materials to ensure consistency and accuracy in claims processing.
• Lead claims review meetings with internal teams and external clients to discuss trends, challenges, and performance metrics.

Client & Vendor Management

• Serve as the primary escalation point for employer groups, brokers, and providers regarding claims inquiries and disputes.
• Work with network providers, TPAs, PBMs, and stop-loss carriers to resolve claim payment issues and contractual disputes.

Qualifications & Skills

Required

• 5 years of experience in health insurance claims management, preferably within a TPA, health plan, or stop-loss carrier.
• Strong understanding of self-funded, level-funded, and MEC/MVP plan designs and claims processing methodologies.
• Expertise in claims adjudication systems.
• Knowledge of ICD-10, CPT, HCPCS coding, and provider reimbursement methodologies (UCR, RBRVS, DRG, etc.).
• Familiarity with ERISA, ACA, HIPAA, and stop-loss reimbursement processes.
• Strong leadership skills with experience managing claims teams and working cross-functionally.
• Proficiency in Excel and claims analytics tools to analyze trends and generate insights.

Preferred

• Experience working with TPA operations and third-party claim administrators.
• Knowledge of subrogation, coordination of benefits (COB), and fraud detection methodologies.
• Familiarity with AI-driven claims processing or automation technologies.
• Industry certifications (e.g., AHIP, CEBS, Certified Claims Professional (CCP)) are a plus.