Senior Manager, Claims

🕒 vor 26 Tagen

🎸 Tennessee – Remote

🎸 Tennessee – Remote

💵 $74.800 - $102.300 / Jahr

⏰ Vollzeit

🟠 Senior

👔 Manager

🦅 H1B-Visum-Sponsor

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Tivity Health

WebsiteLinkedInAlle Stellen

501 - 1000 Mitarbeiter

Gegründet 1981

⚕️ Krankenversicherung

🧘 Wellness

💰 Post-IPO Equity im 2013-10

Healthcare Insurance • Wellness • Fitness

Tivity Health ist ein Unternehmen, das sich der Verbesserung der Gesundheitsergebnisse und der Senkung der Gesundheitskosten durch innovative Fitness- und Wellnessprogramme widmet. Es ermöglicht insbesondere älteren Menschen, sich körperlich zu betätigen und ihre Gesundheit insgesamt zu verbessern, durch Marken wie SilverSneakers, das aktives Leben für Senioren fördert, und Prime Fitness, das landesweit Zugang zu Fitnessstudios bietet. Tivity Health legt Wert auf einen mitgliederzentrierten, datengesteuerten Ansatz, um gesundes Verhalten in verschiedenen Lebensphasen zu fördern und Gesundheit und Wellness für alle zugänglich zu machen.

Beschreibung

• 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.

🎯 Anforderungen

• 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)

🏖️ Vorteile

• 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