Sr Manager, Claims in United States at Jobgether

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Sr Manager, Claims in United States.

This leadership role is responsible for overseeing end-to-end claims operations within a regulated healthcare environment, ensuring accuracy, compliance, and operational excellence across all claims processes. You will lead and develop a high-performing claims organization while partnering closely with cross-functional stakeholders across legal, finance, IT, and vendor teams. The role requires a strong balance of strategic leadership and hands-on operational oversight, with accountability for performance metrics, risk mitigation, and regulatory adherence. You will serve as a key escalation point for complex claims issues while driving continuous improvement through automation and process optimization. This position also plays a critical role in ensuring audit readiness and compliance with healthcare regulations such as CMS and HIPAA. It is a high-impact role that directly influences service quality, cost efficiency, and customer experience across claims operations.

• Lead end-to-end claims operations, ensuring accuracy, timeliness, and compliance with service level agreements and internal standards.
• Manage and develop a team of claims professionals, supervisors, and analysts across multiple functional areas.
• Establish, track, and improve key performance indicators including cycle time, accuracy, denial rates, and cost per claim.
• Drive process improvement and automation initiatives to enhance efficiency and reduce manual workflows.
• Oversee risk management activities, including identification, mitigation planning, escalation protocols, and business continuity planning.
• Monitor fraud, waste, and abuse indicators and coordinate investigations with internal and external stakeholders.
• Ensure compliance with CMS, HIPAA, and state-level healthcare regulations, translating requirements into operational policies.
• Lead audit preparation and act as the primary point of contact during internal and external audits.
• Collaborate with IT, legal, finance, and vendors to align systems, workflows, and operational objectives.
• Present operational performance, risk insights, and compliance updates to senior and executive leadership.
• Support strategic initiatives such as product expansions, system implementations, acquisitions, and client onboarding.

Requirements:

• Bachelor’s degree in Business, Healthcare Administration, Finance, or a related field (or equivalent experience).
• 7–10 years of experience in claims operations, including 3–5 years in a leadership or management role.
• Strong background in regulated industries such as healthcare or insurance, preferably with Medicare Advantage, Medicaid, or supplemental health plans.
• Proven experience developing and executing compliance programs aligned with CMS, HIPAA, or similar frameworks.
• Experience managing operational audits, regulatory reviews, or accreditation processes.
• Demonstrated ability to lead cross-functional teams and collaborate with executive stakeholders.
• Strong analytical, problem-solving, and data interpretation skills.
• Experience with claims systems, workflow tools, and automation initiatives (Plexis/Orion experience a plus).
• Excellent communication, presentation, and organizational skills with strong attention to detail.
• Relevant certifications such as CPC, CHC, Six Sigma, or AIC are preferred.

Benefits:

• Competitive salary ranging from $74,800 to $102,300, depending on experience and qualifications.
• Annual bonus eligibility based on performance.
• Comprehensive medical, dental, and vision insurance coverage.
• 401(k) retirement plan with company match.
• Generous paid time off and holiday policies.
• Free gym membership access to over 13,000 fitness locations across the U.S.
• Employee wellness programs supporting physical, mental, and social well-being.
• Opportunities for career growth within a mission-driven healthcare organization.