索赔运营经理
Senior Manager, Claims Operations
高级经理，理赔运营
我们正在寻找一位经验丰富的高级经理，负责领导和加强我们的理赔职能，帮助建立必要的流程、控制、报告和技术基础设施，以支持我们的持续增长。
职位概述
高级经理，理赔运营将主要负责监督MediDrive的端到端理赔运营，包括理赔提交、审核、对账、就诊报告、付款通知处理、供应商付款支持以及与理赔相关的财务报告。该职位将与运营、财务、会计、产品、技术以及我们的医疗客户紧密合作，确保理赔准确处理、完全对账并适当报告。
本职位的关键部分是理解并管理835付款通知文件、837理赔/就诊交易、医疗补助就诊报告、医疗损失比率（MLR）报告以及与交通相关的理赔和供应商付款。
这是一个需要亲力亲为的领导职位。成功的候选人不仅要管理现有的理赔流程，还需识别差距、制定解决方案、建立控制措施和KPI，并帮助创建可扩展的理赔运营模式，以支持MediDrive的持续发展。
主要职责
理赔运营与管理
- 领导日常理赔工作，监督从初始提交到审核、付款、拒付、调整和最终对账的完整理赔生命周期。
- 制定并维护可扩展的理赔工作流程、政策、程序和内部控制。
- 监控理赔数量、付款活动、未结理赔、拒付、拒绝、调整和异常情况。
- 识别重复、被拒、错误处理或未解决的理赔，并推动问题解决。
- 建立理赔逾期和异常管理流程，确保未决事项及时识别和解决。
- 确保理赔运营符合相关合同、客户、医疗补助和监管要求。
835 / 837 与就诊管理
- 监督835电子付款通知（ERA）文件的处理、验证和对账。
- 管理并理解837医疗理赔和就诊交易，包括提交、接受、拒绝和对账。
- 监督医疗补助就诊报告，并确保提交的就诊数据准确无误。
查看英文原文
Senior Manager, Claims Operations
We are seeking an experienced Senior Manager, Claims Operations to lead and strengthen our claims function and help build the processes, controls, reporting, and technology infrastructure necessary to support our continued growth.
Position Summary
The Senior Manager, Claims Operations will have primary responsibility for overseeing MediDrive's end-to-end claims operations, including claims submission, adjudication, reconciliation, encounter reporting, remittance processing, provider payment support, and claims-related financial reporting.This individual will work closely with Operations, Finance, Accounting, Product, Technology, and our healthcare clients to ensure claims are processed accurately, reconciled completely, and reported appropriately.
A critical component of this position will be the ability to understand and manage 835 remittance files, 837 claims/encounter transactions, Medicaid encounter reporting, Medical Loss Ratio (MLR) reporting, and transportation-related claims and provider payments.
This is a hands-on leadership role. The successful candidate will not only manage existing claims processes but will also identify gaps, develop solutions, establish controls and KPIs, and help create a scalable claims operating model as MediDrive continues to grow.
Key Responsibilities
Claims Operations & Management
- Lead the day-to-day operation of the claims function and oversee the complete claims lifecycle from initial submission through adjudication, payment, denial, adjustment, and final reconciliation.
- Develop and maintain scalable claims workflows, policies, procedures, and internal controls.
- Monitor claims volumes, payment activity, outstanding claims, denials, rejections, adjustments, and exceptions.
- Identify duplicate, rejected, incorrectly processed, or unresolved claims and drive issues through resolution.
- Establish claims aging and exception-management processes to ensure outstanding items are identified and resolved timely.
- Ensure claims operations comply with applicable contractual, client, Medicaid, and regulatory requirements.
835 / 837 & Encounter Management
- Oversee the processing, validation, and reconciliation of 835 Electronic Remittance Advice (ERA) files.
- Manage and understand 837 healthcare claims and encounter transactions, including submission, acceptance, rejection, and reconciliation.
- Oversee Medicaid encounter reporting and ensure submitted encounter data is complete, accurate, and reconciled to underlying claims and transportation activity.
- Work closely with Technology and Product teams to identify and resolve EDI, data, claims-processing, and system integration issues.
- Develop controls to ensure claims and encounter files are successfully transmitted, accepted, and appropriately reflected in downstream financial and operational systems.
Medical Loss Ratio (MLR) & Financial Reconciliation
- Partner with Finance and Accounting to support accurate and timely Medical Loss Ratio (MLR) reporting and analysis.
- Reconcile claims and transportation expenses to client funding, provider payments, remittance activity, and financial reporting.
- Assist Finance with month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and other claims-related accounting requirements.
- Provide visibility into claims trends and cost drivers that may impact client profitability and MLR performance.
- Ensure appropriate reconciliation between operational claims systems and the General Ledger.
Transportation Provider Payments
- Oversee claims-related processes supporting payments to transportation providers.
- Develop controls to ensure transportation providers are paid accurately and only for properly validated and approved transportation services.
- Reconcile provider payments to underlying trip and claims data.
- Partner with Finance and Operations on provider payment processes, including payments made through RAMP or similar payment platforms.
- Identify payment discrepancies, duplicate payments, missing payments, and other exceptions and ensure timely resolution.
Reporting, Analytics & Controls
- Develop and maintain claims dashboards, KPIs, and management reporting, including:
- Claims submitted, accepted, rejected, and paid
- Claims aging
- Denials and rejection rates
- Payment turnaround times
- Outstanding and unresolved claims
- Encounter submission and acceptance rates
- Provider payment reconciliations
- MLR and claims cost trends
- Establish measurable service levels and performance standards for the claims function.
- Provide senior management with clear visibility into claims performance, financial exposure, operational risks, and emerging trends.
- Continuously evaluate claims processes and identify opportunities for automation, improved controls, and increased efficiency.
Cross-Functional Leadership
- Serve as a key liaison between Claims, Finance, Accounting, Operations, Product, Technology, and Compliance.
- Partner with Product and Technology teams to help design and enhance MediDrive's claims technology infrastructure.
- Work directly with healthcare clients and internal stakeholders to resolve claims, encounter, reconciliation, and reporting issues.
- Support audits, client reviews, and requests for claims-related documentation.
- Help build and develop the Claims team as MediDrive's transaction volumes and client base continue to grow.
Qualifications
Required
- Bachelor's degree in healthcare administration, finance, accounting, business, information systems, or a related field, or equivalent relevant professional experience.
- 5+ years of healthcare claims operations experience, with demonstrated responsibility for high-volume claims processing, reconciliation, or payment operations.
- Strong hands-on experience with 835 remittance files and 837 claims/encounter transactions.
- Experience with Medicaid, managed care, health plans, TPA operations, NEMT, or another healthcare claims environment.
- Experience supporting or analyzing Medical Loss Ratio (MLR) calculations and claims cost reporting.
- Strong understanding of claims adjudication, denials, adjustments, reconciliation, and encounter reporting.
- Experience developing claims controls, reconciliations, dashboards, KPIs, and management reporting.
- Strong analytical skills with the ability to identify discrepancies across large volumes of claims and payment data.
- Ability to work effectively across Finance, Accounting, Operations, Product, Technology, and Compliance functions.
Strongly Preferred
- Direct experience within Non-Emergency Medical Transportation (NEMT), transportation benefits, or healthcare transportation.
- Experience with Medicaid transportation claims and encounter reporting.
- Experience reconciling transportation provider payments to claims and trip-level data.
- Familiarity with RAMP or similar provider/payment platforms.
- Experience helping build or scale a claims operation within a rapidly growing organization.
- Experience working with claims technology, EDI platforms, or claims management systems.
- Advanced Excel and data analysis skills.
What We Are Looking For
The ideal candidate is a hands-on claims leader who understands both the operational and financial sides of healthcare claims. This person should be equally comfortable reviewing an 835 or 837 file, investigating a claims reconciliation discrepancy, analyzing MLR performance, working with a technology team on a claims workflow, and explaining claims trends to senior leadership.We are looking for someone who is highly organized, analytical, detail-oriented, and comfortable operating in a fast-growing environment where processes are continually being developed and improved.Most importantly, this individual should have the ability to take ownership of the claims function and help build a scalable infrastructure capable of supporting MediDrive's continued national growth.
Compensation
The anticipated base salary range for this full-time position is $100,000–$110,000 annually, depending on experience and qualifications.
This is a full-time remote position within the United States.
Originally posted on Himalayas