Senior Claims Configuration Manager

🕒 Outubro 26

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $110.500 - $150.000 / ano

⏰ Tempo Integral

🟠 Sênior

👔 Gerente

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• As vagas desta empresa costumam ser preenchidas em 23 dias.

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Devoted Health

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 2017

🏥 Saúde

⚕️ Seguro de Saúde

🧘 Bem-estar

Healthcare • Healthcare Insurance • Wellness

A Devoted Health é uma empresa de saúde que oferece planos Medicare Advantage projetados para fornecer cobertura de saúde abrangente com benefícios adicionais como cuidados dentários, óculos, associações a academias e medicamentos prescritos a preços competitivos. A empresa enfatiza o suporte e serviço ao membro, garantindo que os clientes possam navegar facilmente por seus benefícios e acessar os serviços de saúde necessários. A Devoted Health está comprometida em ajudar os clientes a economizar dinheiro e melhorar sua saúde e bem-estar por meio de um pacote completo de benefícios e suporte.

Descrição

• Own the auto-adjudication rate as a core operational metric • Develop a deep understanding of flags and pend reasons routing claims to manual review • Evaluate flags for business value, accuracy, and operational cost • Partner with Engineering to retire, refine, or automate flags and design new ones where risk warrants human review • Serve as the go-to expert on matching claims to provider contracts and contract groups • Identify and resolve provider contract mismatches leading to incorrect payment • Partner with Provider Operations and Network to align contract intent with claims processing • Own logic generating member EOBs and provider EOPs • Ensure communications accurately reflect adjudication outcomes, member cost share, and denial or adjustment reasons • Ensure member-facing communications meet CMS requirements and provider-facing communications support payment reconciliation • Serve as subject matter expert on remittance outputs, including 835/ERA files and payment reconciliation • Support providers, Provider Services, and Engineering in resolving remit issues and drive root-cause fixes • Proactively identify adjudication, matching, and communication errors • Lead root cause analysis and drive sustainable fixes with Engineering, Claims Operations, and Network/Provider Operations • Establish and own claims logic performance measurement framework • Build audits, validation testing, KPIs, and reporting for payment outcomes • Recommend improvements addressing regulatory changes, new contract structures, and emerging technology to reduce manual work, payment errors, provider abrasion, and operational risk

🎯 Requisitos

• 6+ years of experience in business operations or operational leadership • Comfort with ambiguity and a willingness to dive deep complex claims system logic to fully understand how things work • Exceptional communication skills, with the ability to explain complex claims logic to both technical and non-technical audiences • Demonstrated success in driving meaningful change and measurable operational results in fast-paced environments, with a bias toward action and a focus on continuous improvement • Strong analytical skills, with experience building and developing KPIs, and the ability to work with large claims datasets to diagnose adjudication outcomes and quantify operational and financial impact • Thrives in a fast-paced, metrics-driven environment, with the ability to prioritize and manage multiple initiatives at once • Curiosity and hands-on experience with AI tools, automation, or LLM-based workflows in operational settings is highly desired • Knowledge of health insurance claims processing, particularly Medicare Advantage, including adjudication workflows, provider contracting, and regulatory and compliance requirements • Experience partnering with Engineering on rules-based systems, workflow design, or claims platform development

🏖️ Benefícios

• Employer sponsored health, dental and vision plan with low or no premium • Generous paid time off • $100 monthly mobile or internet stipend • Stock options for all employees • Bonus eligibility for all roles excluding Director and above • Commission eligibility for Sales roles • Parental leave program • 401K program

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