Senior Claims Configuration Manager

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $110.5k - $150k / year

⏰ Full Time

🟠 Senior

👔 Manager

👻 Ghost score 0%

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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