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Senior Manager – Healthcare Claims
Personify Health. Lead and develop a team of claims examiners handling high-risk and complex claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims management, regulatory compliance, and team leadership, with a focus on optimizing processes and enhancing performance metrics. Proficient in managing high-risk claims and ensuring adherence to Medicare, HIPAA, and other regulatory standards.
Highest-signal resume keywords
Claims ManagementRegulatory ComplianceTeam LeadershipProcess ImprovementKPI Analysis
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims Processing SystemsElectronic Data Interchange (EDI)Claims AdjudicationKPI AnalysisProcess Improvement Methodologies
Soft Skills
CoachingPerformance ManagementProblem ResolutionCollaboration
Tools & Technologies
Claims Adjudication Platforms
Industry Keywords
MedicareHIPAADepartment of LaborAudit ResponseCompliance Documentation
About the role
Key responsibilities & impact- Lead and develop a team of claims examiners handling high-risk and complex claims
- Coach, guide, and hold team members accountable while driving performance, engagement, and talent development
- Oversee pended, high-dollar, and special-handling claims from start to finish
- Ensure timely and accurate adjudication in line with policies and service standards
- Resolve escalated claim payment problems and discrepancies
- Partner with internal teams on fraud investigations and escalated inquiries
- Coordinate responses to audits, legal requests, insurance complaints, Department of Labor matters, and regulatory inquiries
- Ensure adherence to Medicare, HIPAA, and applicable regulatory standards
- Conduct ongoing reviews of quality, productivity, and documentation requirements
- Identify workflow gaps, standardize procedures, and implement best practices
- Partner with leadership to increase auto-adjudication rates and reduce manual intervention
- Collaborate with IT, legal, compliance, and vendors on system and process improvements
- Support system enhancements, test and implement updates, and optimize EDI processes
- Track accuracy, productivity, and turnaround metrics and provide recommendations to leadership
- Contribute to implementations, RFP support, and project teams to support successful launches
Requirements
What you’ll need- Bachelor's degree in Business Administration, Health Administration, or a related field preferred
- 7+ years of experience in claims operations, preferably within a TPA environment
- 5+ years of leadership or supervisory experience in claims management
- Deep knowledge of claims processing systems, workflows, and regulatory requirements including Medicare, HIPAA, and DOL
- Experience with electronic data interchange (EDI) processes and claims adjudication platforms
- Proficiency in KPI analysis, reporting, and process improvement methodologies
- Familiarity with audit response processes, compliance documentation, and legal/regulatory coordination
Benefits
Comp & perks- Competitive base salary
- Benefits effective day one
- Comprehensive medical and dental coverage through Personify Health's health solutions
- Unlimited PTO
- Mental health support
- Retirement planning
- Financial protection
- Professional development
- Clear career progression
- Learning budgets
- Wellness programs
- Other employee perks
- Mission-driven culture where diverse perspectives drive real impact