Claims Adjudication Manager

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🏰 Missouri – Remote

🏰 Missouri – Remote

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🟠 Senior

👔 Manager

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Imagenet LLC

WebsiteLinkedInAlle Stellen

1001 - 5000 Mitarbeiter

⚕️ Krankenversicherung

🛍️ eCommerce

☁️ SaaS

💰 Private Equity Round im 2022-12

Healthcare Insurance • eCommerce • SaaS

Imagenet LLC ist ein führender Anbieter von Business-Continuity-Services für Gesundheitsorganisationen und spezialisiert auf digitale Postraumlösungen, Schadenregulierung, Kontaktcenter-Betrieb und Workflow-Management. Mit über zwei Jahrzehnten Erfahrung und dem Ruf, Effizienz und Genauigkeit zu verbessern, arbeitet Imagenet mit Gesundheitsplänen zusammen, um Prozesse zu optimieren und die Mitgliedszufriedenheit zu erhöhen. Ihre Dienstleistungen sind darauf ausgelegt, die Abwicklungszeiten von Ansprüchen zu verkürzen, die Verarbeitungskapazitäten zu erhöhen und die Wartezeiten im Kontaktcenter zu verkürzen. Durch die Integration skalierbarer Lösungen, die auf spezifische Bedürfnisse zugeschnitten sind, ermöglicht Imagenet Gesundheitsorganisationen, die Produktivität zu steigern und operative Herausforderungen zu bewältigen.

Beschreibung

• 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.

🎯 Anforderungen

• 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.

🏖️ Vorteile

• Remote work • Flexible schedules • Professional development opportunities