Manager, Medical Claims at Heritage Health Solutions – Coppell, Texas

Position Summary

The Manager of Medical Claims oversees the daily operations, performance, and strategic direction of the medical claims audit and adjudication function. This role ensures that claims are processed accurately, efficiently, and in compliance with applicable regulations while leading, coaching, and developing a team of Medical Claims Analysts. The Manager partners with internal stakeholders to improve claim outcomes, reduce duplicates and denials, and support organizational financial and compliance objectives.

Essential Duties and Responsibilities

• Provide direct leadership, coaching, and performance management to a team of Medical Claims Analysts.
• Oversee the review, audit, and adjudication of medical claims to ensure accuracy, compliance, and timely reimbursement.
• Establish and monitor productivity, quality, and turnaround-time metrics for the claims team.
• Guide escalation and resolution of complex, high-dollar, or high-risk claims and appeals.
• Analyze denial trends, root causes, and process gaps; develop and implement corrective action plans.
• Ensure appropriate application of ICD-10, CPT, and HCPCS coding standards across claim reviews.
• Collaborate with providers, payers, compliance, and internal departments to resolve systemic claims issues.
• Ensure team adherence to federal and state regulations, including Medicare, Medicaid, and HIPAA requirements.
• Develop and update policies, procedures, and training materials related to claims processing and auditing.
• Utilize reporting tools and claims management systems to track performance, savings, and operational effectiveness.

Qualifications

• Education: High School Diploma or GED required; Associate’s or Bachelor’s degree in healthcare administration, business, or a related field preferred.
• Experience: Progressive experience and certifications in medical claims processing, billing, or coding, including prior leadership or supervisory experience.
• Advanced knowledge of medical terminology, ICD-10, CPT, HCPCS coding, and insurance reimbursement methodologies (PPO, HMO, DRG).
• Demonstrated experience managing workflows, KPIs, and performance metrics in a claims or revenue cycle environment.
• Strong proficiency in Microsoft Office applications, particularly Excel, and healthcare claims management systems.

Leadership Skills and Competencies

• Proven ability to lead, coach, and develop high-performing teams.
• Strong analytical and decision-making skills, with the ability to interpret data and drive process improvement.
• Effective verbal and written communication skills, including the ability to interact with internal leaders, providers, and payers.
• High level of attention to detail and accountability in a regulated environment.
• Ability to manage multiple priorities and adapt to changing business needs.

Compliance and Confidentiality

Ensures the medical claims function operates in compliance with all federal, state, and company policies, including HIPAA privacy and security standards. Maintains strict confidentiality and promotes ethical conduct across the team.