Senior Claims Operations Manager

Job Summary

Leading the claims function in a full-time remote capacity, the Senior Claims Operations Manager will oversee end-to-end claims operations, including submission, adjudication, and financial reporting, while developing scalable processes and controls to support organizational growth.

Key Responsibilities

• Manage the complete claims lifecycle from submission through reconciliation, ensuring compliance with regulatory requirements
• Oversee the processing and validation of 835 remittance files and 837 claims/encounter transactions, collaborating with technology teams to resolve issues
• Partner with Finance and Accounting to support Medical Loss Ratio (MLR) reporting and reconcile claims-related financial data

Required Qualifications

• Bachelor's degree in healthcare administration, finance, accounting, business, information systems, or a related field, or equivalent professional experience
• 5+ years of healthcare claims operations experience with high-volume claims processing and reconciliation
• Strong hands-on experience with 835 remittance files and 837 claims/encounter transactions
• Experience with Medicaid and managed care environments, including MLR calculations and claims cost reporting
• Proven ability to develop claims controls, dashboards, and management reporting