Claims Processing and Quality Manager

The Claims Processing and Quality Manager oversees the daily operations of the claims department, ensuring claims are processed accurately, efficiently, and in compliance with company policies and regulatory requirements. This role provides leadership, guidance, and technical support to claims staff while driving workflow efficiency, quality assurance, and continuous improvement. Manager of Claims Processing and Quality has a focus on direct member reimbursement processing and tracking, Medicare/Medicaid subrogation claims processing and new client implementation testing.

Must report on site 5 days a week

Key Responsibilities

Claims Operations Management

• Oversee day‑to‑day claims processing to ensure accuracy, efficiency, and compliance with regulations and internal policies
• Monitor claims inventory, assignments, and turnaround times to meet departmental service goals
• Oversee the resolution of complex claims issues and act as the primary escalation point
• Perform 2nd set of eyes on DMR claims processed by Claims Processors
• Timely address DMR related questions from other internal departments

New Client Implementations Testing Management

• Oversee end‑to‑end implementations testing for new client builds, including test case development, scenario creation, and validation of adjudication outcomes
• Ensure all claims testing aligns with client contracts, benefit summaries, regulatory requirements, and organizational standard
• Ensure testing environments accurately reflect production design and escalate discrepancies as needed

Medicare/Medicaid Subrogation Management

• Oversee Medicare and Medicaid subrogation claim processing to ensure compliance with state and federal recovery requirements
• Partner with internal and external stakeholders to support accurate investigation, documentation, and recovery efforts

Staff Management

• Oversee daily scheduling and assignment of employee tasks to ensure balanced workloads and operational efficiency.
• Manage employee PTO requests and oversee payroll processes
• Conduct interviews and participate in the selection process for open departmental positions
• Facilitate departmental, cross‑departmental, and individual employee meetings to support communication and alignment
• Develop, update, and maintain process documentation, desktop procedures, and operational framework

Qualifications:

Required

• 3+ years of experience in claims processing or a related insurance field

• At least 2 years in a supervisory or leadership role
• Ability to work in a fast‑paced environment with shifting priorities.
• Strong Microsoft Excel skills
• Minimum of 12 months of prior claims processing experience and PBM terminology

Preferred

• Strong leadership and team management skills with the ability to coach, train, and motivate staff
• Problem-solving ability to investigate missing information or discrepancies
• Organizational skills for managing workload
• Strong understanding of PBM operations.