Senior Claims Operations Manager

1 month ago

Reno, Nevada, United States Prominence Health Full time

About Prominence Health

Prominence Health is a value-based care organization that bridges the gap between affiliated health systems and independent providers, fostering trust and collaboration between the two. Our organization creates value for populations and providers by strengthening integrated partnerships, advancing market opportunities, and improving outcomes for our patients and members.

Job Summary

The Senior Claims Manager will oversee and ensure the efficiency and accuracy of healthcare claims operations. This position will oversee the claims inventory by setting, evaluating, and monitoring the claims inventory and examiner production metrics, and is responsible for timely and precise benefit determinations for claims, while upholding exceptional service standards for both members and providers.

Key Responsibilities

  • Oversee the claims inventory and ensure timely and precise benefit determinations for claims.
  • Set, evaluate, and monitor claims inventory and examiner production metrics.
  • Implement and advocate for excellence in quality processes and compliance standards.
  • Proactively identify areas for improvement and provide coaching to team members.
  • Ensure the attainment of key performance metrics.
  • Participate in various meetings and company initiatives to support claims integrity.

Requirements

  • Bachelor's degree in healthcare administration or business management, or equivalent work experience.
  • 5+ years' experience with a healthcare company or a health plan.
  • 5+ years' experience managing, budgeting, forecasting, and collaboration with executive leadership.
  • Strong leadership skills with an ability to influence and persuade internally and externally while driving cross-functional collaboration.
  • In-depth knowledge of medical terminology, coding systems (CPT, ICD-), and insurance billing practices.
  • Strong understanding of healthcare regulations, including HIPAA, CMS guidelines, state laws, and experience in information preparation for required regulatory audits.
  • Ability to promote data-driven decision making throughout the organization.
  • Knowledge of benefits, pricing, and inventory management and reporting.
  • Expertise in software implementation, technology adoption, and an understanding of which tools work best to meet the needs of the organization.
  • Outstanding interpersonal skills.
  • Excellent written, oral, and active listening communication skills.
  • Proficient in MS Office, contact center, and training platforms, workforce management, and project/team management software.
  • Strong project management skills and experience managing large-scale projects.
  • QNXT system experience preferred.
  • Ability to effectively communicate in English, both verbally and in writing.
  • Excellent computer skills.
  • Highly developed professional, interpersonal, written, and oral communication skills.
  • Experience in building and maintaining provider relationships.
  • Highly accountable, organized, and detailed.
  • Ability to develop and implement strategic initiatives.

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