Program Manager - Claims, Health Plan
Core
Manage claims escalations, provider issues, pricing, and payment policy interpretation for a nonprofit health plan serving older adults.
Role type
Senior Program Manager (Health Plan Claims)
Builds
Claims adjudication processes, Total Cost of Care initiatives, and claims-platform upgrades.
Domain
Healthcare / Medicare Advantage / Health Insurance
Required skills
Claims adjudication, claims operations, pricing, payment policy interpretation, NCD/LCD interpretation, complex claim investigation, data analysis, cross-functional program management, vendor management, system implementation testing, resource allocation, leadership, problem solving, process optimization, Microsoft Office Suite, Visio, SQL
Preferred skills
Medicare Advantage claims operations experience, regulatory requirements knowledge
Technologies
Microsoft Office Suite, Visio, SQL
Responsibilities
Manage claims escalations, provider abrasion, service issues, pricing matters, and payment policy interpretation; Investigate and resolve complex, high-dollar claims; Analyze claims and operational data to identify trends and cost savings; Lead claims triage and management for AEP/OEP; Support Total Cost of Care initiatives; Support staffing plans and resource allocation; Manage vendor or third-party claims relationships; Support system implementations and claims-platform upgrades.
Seniority
Senior, hands-on IC with leadership responsibilities
