• Claims Manager- Benefits

    Job Location(s) US-NV-Las Vegas
    Job ID
    # of Openings
    Benefits Administration
    Job Type
    Regular Full-Time
  • Overview

    POSITION SUMMARY: Under minimal supervision, manages and directs all aspects of claims processing operations and provides technical support and training. Manages production and quality assurance outcomes to ensure compliance with applicable performance guarantees and contractual obligations. Ensures compliance with applicable state and federal laws.






    • Maintain and revise, as appropriate, policies and procedures for claims operations.
    • Monitor and develop training and/or procedures to ensure that claims operations are operating within all statutory requirements and plan benefit document requirements.
    • Manage claim inventory and production requirements.
    • Create and distribute pend and suspend reports on a regular basis to ensure claims are timely processed and meeting turnaround time requirements.
    • Coordinate and lead department meetings for staff on updated laws, policies and procedures and document meeting purpose and attendees present.
    • Respond to client, claimant and vendor concerns and issues timely and as applicable.
    • Ensure compliance with applicable TPA credentialing compliance (SOC1)
    • Facilitate all aspects related to internal and external audits.
    • Ensure adherence to applicable client servicing instructions.
    • Provide coverage for personnel due to vacation, vacancies, increased caseload/projects, or approved leaves.
    • Generate reports as applicable to claims operations or client requirements.
    • Provide analysis of and recommendations for improved claims operations to senior management.
    • Maintain positive and good working relationships with provider community.
    • Assists corporate office and sales/service team for RFP’s and service issues.
    • Responsible for personnel actions including hiring, terminations, corrective action plans, and annual performance reviews for all assigned personnel.
    • Maintain and update standardized letters and forms used in claims operations.
    • Work closely with Plan Builder on system issues or plan design discrepancies as identified.
    • Review, approve, and document exception processing operations stemming from client requests.
    • Work closely with IT to modify and suggest updates to the claims adjudication system(s).
    • Responsible for the execution of other duties and assignments directly or indirectly related to the claims department to ensure that all actions contribute to the overall success of the business not just specific assigned areas of responsibility.





    Education/Experience: Bachelor’s degree in related field (preferred); five (5) years related experience; or equivalent combination of education and experience.


    Knowledge, Skills and Abilities:         

    • Exceptionally strong knowledge of claims handling and applicable regulations/laws.
    • Experience in managing a claims operation with personnel of various skill levels.
    • Technical knowledge of statutory regulations and medical terminology.
    • Ability to prioritize multiple tasks and meet strict deadlines.
    • Capable of establishing an operational budget.
    • Excellent written and verbal communication skills, including the ability to convey technical details to claimants, clients, and staff.
    • Possess excellent computer literacy skills with a variety of software programs and adjudication systems.
    • Ability to read, understand, analyze, and interpret claim reports/data.
    • Effectively present information and respond to questions from corporate office, other branches, clients and vendor community.
    • Ability to communicate with all staff levels within the organization.
    • Must be able to travel and work extended hours and work weeks.


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