Senior Manager, Claims Operations

🕒 Yesterday

🇺🇸 United States – Remote

💵 $100k - $110k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

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MediDrive, LLC

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2023

🏥 Healthcare

🚗 Transport

☁️ SaaS

Healthcare • Transport • SaaS

MediDrive is a technology-driven company providing a nationwide Non-Emergency Medical Transportation (NEMT) platform and transportation management system that connects health plans, healthcare providers, transportation providers, and members. The company operates across 48 states, managing tens of thousands of daily trips (20K+), delivering a reported 95% on-time performance and offering a broad vehicle network including ambulatory, wheelchair-accessible, and ambulette options. MediDrive emphasizes automation and analytics—claiming high levels of automated ride management, advanced routing and cost optimization, data insights, fraud prevention, and dedicated account support—while maintaining regulatory and security standards (HIPAA, SOC 2, ISO 27001).

📋 Description

• Lead the day-to-day operation of the claims function and oversee the complete claims lifecycle from initial submission through adjudication, payment, denial, adjustment, and final reconciliation • Develop and maintain scalable claims workflows, policies, procedures, and internal controls • Monitor claims volumes, payment activity, outstanding claims, denials, rejections, adjustments, and exceptions • Identify duplicate, rejected, incorrectly processed, or unresolved claims and drive issues through resolution • Establish claims aging and exception-management processes • Ensure claims operations comply with contractual, client, Medicaid, and regulatory requirements • Oversee processing, validation, and reconciliation of 835 Electronic Remittance Advice files • Manage 837 healthcare claims and encounter transactions, including submission, acceptance, rejection, and reconciliation • Oversee Medicaid encounter reporting and reconcile encounter data to underlying claims and transportation activity • Partner with Technology and Product teams to resolve EDI, data, claims-processing, and system integration issues • Develop controls for claims and encounter file transmission, acceptance, and downstream system reflection • Support Medical Loss Ratio (MLR) reporting and analysis • Reconcile claims and transportation expenses to client funding, provider payments, remittance activity, and financial reporting • Assist Finance with month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and claims-related accounting requirements • Provide visibility into claims trends and cost drivers affecting client profitability and MLR performance • Ensure reconciliation between operational claims systems and the General Ledger • Oversee claims-related processes supporting transportation provider payments • Develop controls for accurate payments to transportation providers • Reconcile provider payments to underlying trip and claims data • Partner with Finance and Operations on provider payment processes, including RAMP or similar platforms • Identify and resolve payment discrepancies, duplicate payments, missing payments, and other exceptions • Develop and maintain claims dashboards, KPIs, and management reporting • Establish measurable service levels and performance standards • Provide senior management with visibility into claims performance, financial exposure, operational risks, and emerging trends • Evaluate claims processes for automation, improved controls, and increased efficiency • Liaise between Claims, Finance, Accounting, Operations, Product, Technology, and Compliance • Help design and enhance MediDrive's claims technology infrastructure • Work with healthcare clients and internal stakeholders to resolve claims, encounter, reconciliation, and reporting issues • Support audits, client reviews, and claims-related documentation requests • Help build and develop the Claims team as transaction volumes and the client base grow

🎯 Requirements

• Bachelor's degree in healthcare administration, finance, accounting, business, information systems, or a related field, or equivalent relevant professional experience • 5+ years of healthcare claims operations experience • Demonstrated responsibility for high-volume claims processing, reconciliation, or payment operations • Strong hands-on experience with 835 remittance files and 837 claims/encounter transactions • Experience with Medicaid, managed care, health plans, TPA operations, NEMT, or another healthcare claims environment • Experience supporting or analyzing Medical Loss Ratio (MLR) calculations and claims cost reporting • Strong understanding of claims adjudication, denials, adjustments, reconciliation, and encounter reporting • Experience developing claims controls, reconciliations, dashboards, KPIs, and management reporting • Strong analytical skills with the ability to identify discrepancies across large volumes of claims and payment data • Ability to work effectively across Finance, Accounting, Operations, Product, Technology, and Compliance functions • Direct experience within Non-Emergency Medical Transportation (NEMT), transportation benefits, or healthcare transportation strongly preferred • Experience with Medicaid transportation claims and encounter reporting strongly preferred • Experience reconciling transportation provider payments to claims and trip-level data strongly preferred • Familiarity with RAMP or similar provider/payment platforms strongly preferred • Experience helping build or scale a claims operation within a rapidly growing organization strongly preferred • Experience working with claims technology, EDI platforms, or claims management systems strongly preferred • Advanced Excel and data analysis skills strongly preferred