Job Role Description

Medical > Medical Claims Manager

Salary National Average

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52490.0000 63280.0000 80370.0000

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Short Description:

A Medical Claims Manager oversees the administration and processing of healthcare claims, ensuring that claims are handled efficiently, accurately, and in compliance with regulatory guidelines. Their responsibilities include managing a team of claims adjusters and assistants, reviewing complex or disputed claims, and implementing strategies to improve the claims process. Medical Claims Managers also monitor claims data to identify trends, ensure adherence to healthcare policies, and collaborate with other departments to resolve issues. Strong leadership, analytical skills, and a deep understanding of healthcare billing and insurance practices are essential for success in this role, as Medical Claims Managers play a critical role in optimizing claims operations and maintaining compliance.

Duties / Responsibilities:

  • Manage day-to-day operations of the claims department and provide general oversight and direction of all claim activity.
  • Review operations systems and procedures, recommend improvements to increase efficiency and participate in projects to achieve optimization goals.
  • Retain and manage outside counsel; develop and coordinate strategy for litigation; participate in alternative dispute resolution and negotiate settlements.
  • Create departmental policies and procedures based on Medicare and Medicaid regulations.
  • Identify and discuss legal issues with worker's compensation attorneys and frequent communication with the insured.
  • Attend all mediations and critical trials.
  • Respond to all DOI questions and concerns.
  • Work with TPA, service providers, and personnel to design, implement, and manage wellness programs.
  • Provide authority, as warranted, on all aspects of nationally handled TPA files, including reserve adequacy and settlement values.

Skills / Requirements / Qualifications

  • Active Listening: Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
  • Reading Comprehension: Understanding written sentences and paragraphs in work related documents.
  • Speaking: Talking to others to convey information effectively.
  • Critical Thinking: Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
  • Monitoring: Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action.
  • Time Management: Managing one's own time and the time of others.
  • Education: Bachelor's degree in business administration or a related discipline is necessary; a master's degree preferred
  • Experience: At least three years of experience as an insurance claims adjuster, claims examiner, or claims supervisor, one of which was in a leadership position.
  • Skills: Must have a thorough understanding of insurance-related legal procedures, regulations, and claims processing
  • Software Skills: Strong proficiency in Microsoft Office computer programs, including Excel, Word, and other programs

Job Zones

  • Education: Most of these occupations require a four-year bachelor's degree, but some do not.
  • Related Experience: A considerable amount of work-related skill, knowledge, or experience is needed for these occupations. For example, an accountant must complete four years of college and work for several years in accounting to be considered qualified.
  • Job Training: Employees in these occupations usually need several years of work-related experience, on-the-job training, or vocational training.
  • Job Zone Examples: Many of these occupations involve coordinating, supervising, managing, or training others. Examples include real estate brokers, sales managers, database administrators, graphic designers, conservation scientists, art directors, and cost estimators.

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