Claims Manager

Responsible for managing the claims department composed of Claims Analyst and Quality Analyst. Oversee operations of multiple claims operating systems, including the timely and proper repricing of claims in accordance with network agreements. Oversees insurance claims for Workers Comp, Medical, RBP and Dental. Requires a bachelor's degree or equivalent experience in the insurance industry. Typically reports to AVP of Operations. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. Typically requires 3+ years of managerial experience.
KEY RESPONSIBILITIES:

• Oversees claim flow and scheduling of processing and analysis departments.
• Directs processors to ensure adherence to standard operating procedures in client communication, document and file creation, data storage, and invoicing.
• Can perform all functions relating to client communication of claim information and results, document and file creation, data storage and invoicing.
• Must be able to utilize special company systems and software.
• Participate in other projects as assigned.
• Design and implement various policies and procedures for claims.
• Provide services to all business requirements and ensure optimal handling of all claims and investigate all issues and provide training for all business units.
• Ensure the proper training of all analyst on all new products, networks and client specific rules.
• Review existing policies and procedures and updating them as needed.
• Monitor effectiveness of all departmental policies and provide support team to ensure that they are carried out effectively.
• Analyze all claims to ensure optimal quality and prepare monthly and quarterly reports to the executive leadership team.
• Analyze all claims and identify all risks and ensure processing of all claims as per company policy.
• Forecast all staffing requirements and identify and resolve all issues effectively.

PROFESSIONAL EXPERIENCE:
To perform this job successfully, it is essential that an individual perform all duties and responsibilities satisfactorily and demonstrate the following knowledge, skills, and abilities:

• Must be able to work in a fast-paced environment with multiple priorities and time-sensitive deadlines.
• Must be able to manage multiple projects simultaneously.
• Must be available and accessible during the company’s core business hours.
• Must possess strong leadership and interpersonal skills, be very detail oriented, and have strong organizational and time management skills.
• Must be able to communicate effectively with managers, coworkers, clients, healthcare providers, and others.
• Must be proficient in all Microsoft Office applications and spreadsheets with emphasis on Word and Excel.
• Must be able to work with minimal supervision.
• Must be able to take direction and complete projects and tasks efficiently, on time, and as assigned.
• Must have previous experience managing a production environment and be able to meet strict turnaround time and quality standards.

EDUCATION:

• Bachelor’s degree or equivalent experience in sales, management, or healthcare billing.
• Experience in the healthcare industry is preferred.

WORK ENVIRONMENT:

• Travel requirements to (primarily) domestic destinations should not exceed 10%.
• A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of the integration, where deadlines exist and when necessary due to the needs of the integration team.
• A standard business environment exists with moderate noise levels.
• Ability to lift and move approximately thirty (30) pounds on a non-routine basis.
• Ability to sit for extended periods of time.

Zelis is a healthcare and financial technology growth company and market-leading provider of claims cost management and payments optimization solutions to price, pay and explain healthcare claims. Zelis delivers integrated network analytics, network solutions, payment integrity, electronic payments and claims communications for payers, healthcare providers and consumers in the medical, dental and workers' compensation markets nationwide. Zelis is backed by Parthenon Capital Partners and Bain Capital.


“We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.”