Senior Manager, Claims

🕒 Maio 11

🎸 Tennessee – Remoto

🎸 Tennessee – Remote

💵 $74.800 - $102.300 / ano

⏰ Tempo Integral

🟠 Sênior

👔 Gerente

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Tivity Health

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 1981

⚕️ Seguro de Saúde

🧘 Bem-estar

💰 Post-IPO Equity em 2013-10

Healthcare Insurance • Wellness • Fitness

Tivity Health é uma empresa dedicada a melhorar os resultados de saúde e reduzir os custos de assistência médica por meio de programas inovadores de fitness e bem-estar. Eles capacitam indivíduos, especialmente a população idosa, a se engajar em atividades físicas e melhorar sua saúde geral por meio de marcas como SilverSneakers, que promove um estilo de vida ativo para idosos, e Prime Fitness, que proporciona acesso a instalações de fitness em todo o país. A Tivity Health enfatiza uma abordagem centrada no membro e orientada por dados para facilitar comportamentos saudáveis em várias fases da vida, tornando a saúde e o bem-estar acessíveis a todos.

Descrição

• Oversee end-to-end claims processing operations, ensuring accuracy, efficiency, and adherence to service level agreements • Lead and develop a team of claims professionals, supervisors, and analysts across multiple claims functions • Establish and monitor KPIs including claim cycle time, denial rates, accuracy rates, and cost per claim • Drive continuous process improvement initiatives leveraging automation and technology to reduce manual touchpoints • Identify, assess, and mitigate operational risks across the claims lifecycle • Develop and maintain a claims risk register, escalation protocols, and inform business continuity plans • Partner with finance and legal teams to assess claims liability exposure and trending • Monitor fraud, waste, and abuse indicators and coordinate investigation protocols with appropriate stakeholders • Ensure claims operations align with federal and state regulations, including CMS guidelines, HIPAA, and applicable plan-specific requirements • Lead audit readiness efforts and serve as the primary operational point of contact during internal and external audits • Maintain current knowledge of regulatory changes and translate compliance requirements into operational policy and procedure updates • Develop and implement compliance training programs for claims staff • Collaborate with IT, legal, finance, and vendor partners to align claims systems and workflows with organizational goals • Present operational performance, risk posture, and compliance status to senior leadership and other stakeholders as needed • Support organizational growth initiatives including new product lines, client implementations, acquisitions, or system migrations from a claims operations perspective • Other duties as assigned.

🎯 Requisitos

• Bachelor’s degree in Business Administration, Healthcare Administration, Finance, or a related field preferred • 7–10 years of progressive experience in claims operations, with at least 3–5 years in a leadership role • Demonstrated experience managing cross-functional teams in a regulated industry, preferably healthcare or insurance • Proven track record of building and executing compliance programs aligned with CMS, HIPAA, or state regulatory frameworks • Experience leading operational audits, responding to regulatory inquiries, or managing accreditation processes • Hands-on experience implementing process automation, claims management systems, or workflow technology • Strong background in risk identification, mitigation planning, and operational controls • Experience presenting to Senior and Executive leadership, Board members, or external regulatory bodies preferred • Commercial, Medicare Advantage, Medicaid, or supplemental health plan experience required • Excellent verbal, written and presentation skills • Excellent problem solving and data analysis ability • Excellent organizational and time management skills • Proficiency using MS Office (Excel, Word, PowerPoint, Access) • Experience using a variety of automated claims processing systems, Plexis/Orion experience a plus • Exceptional customer service skills • Relevant certifications preferred: Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), Six Sigma Green or Black Belt, Associate in Claims (AIC)

🏖️ Benefícios

• Competitive salary • Company bonus potential • Medical, dental, and vision insurance • 401(k) with match • Generous paid time off • Free gym membership to over 13,000 fitness locations in the US • Other great benefits