Claims Operations Manager

Job not on LinkedIn

🔥 1 minute ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $110k - $120k / year

⏰ Full Time

🟠 Senior

🔴 Lead

⚙️ Operations

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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ZING. Enamel Whitening. Toothpaste, but magic.

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2023

💄 Beauty

🛒 Retail

🧘 Wellness

Beauty • Retail • Wellness

ZING is a toothpaste company that specializes in enamel whitening with a unique formulation that promises to dissolve stains, repair enamel, and reduce sensitivity. Proudly made in the UK, ZING's products are vegan, cruelty-free, and 100% recyclable. Their toothpaste is designed to be enjoyable to use while providing effective dental care, with a focus on natural ingredients and sustainability.

📋 Description

• Oversee claims production and vendor oversight for Medicare Advantage line of business • Establish, implement, and improve internal controls and department policies and procedures • Maintain knowledge of government regulations related to claims payments and recognized claims processing standards • Investigate and respond to claims inquiries from members, providers, networks, and government agencies • Ensure quality controls and analyze root causes of claim payment variations • Ensure claim support services achieve provider satisfaction and timely dispute/appeal responsiveness • Work with the Core Configuration team and vendors on claims systems • Coordinate implementation and maintenance of EDI related to claims submissions and processing status • Ensure accurate claims payments and remittance documentation • Identify trends and resolutions to reduce provider disputes • Monitor staff work for quality and efficiency • Provide training, feedback, coaching, and disciplinary action to staff when necessary • Collaborate with departments to resolve issues • Communicate problems to senior leadership • Support Medicare operations compliance with MA Plan contractual requirements and CMS regulations • Monitor day-to-day performance and provide reports to MRx Compliance • Participate in operational and compliance audits • Participate in planning and implementation of new accounts, programs, products, and services • Develop short- and long-range departmental plans and contribute to corporate and strategic plans • Participate in Corrective Action Plans (CAPs) • Assist Quality Improvement efforts in quarterly audits

🎯 Requirements

• Four (4) years minimum in a manager level role or above • Four (4) years of Medicare claims experience required • Medicare/DSNP/ACA Exchange operations experience preferred • Seven (7) years of health plan administration experience