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.
Please apply via our LinkedIn Job Posting: https://www.linkedin.com/jobs/view/4190958437