Claims Adjudication Manager

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🕒 3 dias atrás

🏰 Missouri – Remoto

🏰 Missouri – Remote

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Imagenet LLC

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

⚕️ Seguro de Saúde

🛍️ Comércio Eletrônico

☁️ SaaS

💰 Private Equity Round em 2022-12

Healthcare Insurance • eCommerce • SaaS

Imagenet LLC é um provedor líder de serviços de continuidade de negócios para organizações de saúde, especializado em soluções de central de correspondência digital, adjudicação de sinistros, operações de central de contato e gerenciamento de fluxo de trabalho. Com mais de duas décadas de experiência e uma reputação por aumentar a eficiência e a precisão, a Imagenet faz parcerias com planos de saúde para aprimorar processos e melhorar a satisfação dos membros. Seus serviços são projetados para reduzir o tempo de resposta de sinistros, aumentar a capacidade de processamento e diminuir o tempo de espera em centrais de contato. Ao integrar soluções escaláveis e personalizadas para necessidades específicas, a Imagenet permite que organizações de saúde acelerem a produtividade e mitiguem desafios operacionais.

Descrição

• Provide day-to-day operational leadership for the Philippines-based adjudication team (examiners, auditors, and team leads), working across time zones to direct priorities and remove blockers. • Serve as the hands-on claims SME for the campaign — personally adjudicating complex or escalated claims and modeling correct handling for the team. • Drive accuracy, productivity, quality, and service-level goals; translate client requirements into clear, executable operating procedures. • Partner with the offshore manager and team leads to strengthen communication, information flow, and consistency of execution. • Act as the senior operational single point of contact (SPOC) for the client, consolidating guidance from multiple client stakeholders into one consistent set of directives for the delivery team. • Lead client working sessions, escalations, and operational updates with confidence and credibility; provide clear written and verbal updates on performance, quality, and improvement actions. • Manage frequently changing client requirements — capturing, sequencing, and operationalizing new directives without disrupting production. • Own the quality program: reduce repeat errors, identify root causes, and close coaching gaps through targeted, SME-led feedback. • Align coaching responsibilities with subject-matter expertise; design and lead calibration sessions between examiners and auditors. • Oversee validation of production reporting; partner with the business analyst and client to resolve reporting discrepancies (e.g., over- or under-counting) and establish a trusted tracking methodology. • Use data to identify capacity, monitor service levels, and demonstrate measurable improvement to the client. • Establish and maintain a centralized documentation and knowledge-management process for client directives, reducing reliance on individual knowledge. • Partner with HR and recruiting to accelerate hiring, rebuild the candidate pipeline, and stabilize staffing levels.

🎯 Requisitos

• 6+ years of U.S. healthcare claims adjudication experience, with hands-on expertise in BOTH hospital/facility (UB-04) and professional (CMS-1500/HCFA) claims. • 3+ years leading claims teams (managing 30–40+ examiners/auditors, directly or through team leads), ideally including offshore or BPO/shared-services teams. • Demonstrated ability to serve as a client-facing operational leader — running working sessions, owning escalations, and building client trust. • Strong command of claims workflows, medical terminology, coding concepts, benefits, and payer/provider processes. • Proven track record managing productivity, quality, service levels, and team performance in a metrics-driven environment. • Experience coaching examiners and reducing error rates through structured quality and calibration programs. • Excellent written and verbal communication; able to work effectively across cultures and time zones. • Strong analytical and problem-solving skills, including working with production and quality data.

🏖️ Benefícios

• Remote work • Flexible schedules • Professional development opportunities