Claims Manager

Job Summary

The Claims Manager is responsible for overseeing the end-to-end medical claims process within the HMO, ensuring timely, accurate, and compliant adjudication of member and provider claims. This role leads the claims team, implements process improvements, ensures adherence to regulatory and contractual requirements, and collaborates with internal and external stakeholders to optimize claims performance and member satisfaction.

Key Responsibilities

Claims Operations

• Manage daily claims processing operations, including medical, hospital, and ancillary service claims
• Ensure accurate and timely adjudication of claims in accordance with HMO policies, benefit plans, provider contracts, and regulatory requirements
• Monitor claims turnaround time (TAT), accuracy rates, and denial trends

Team Leadership & Development

• Lead, coach, and supervise claims officers and claims analysts