Healthcare Claims Manager

Job Overview
We are looking for a veteran Medicare Claims Manager, where your expertise will drive the efficiency and accuracy of our claims processing. In this vital role, you will oversee our healthcare claims shop across the entire claims lifecycle in a high-quality, efficient, transparent, consistent and compliant manner. If you know Medicare’s medical policies, reimbursement methodologies and claims processing rules backwards, forwards and sideways, we’d love to speak with you. If you believe that a claim is a story about a member’s health – and that we must understand the story being told so we can put the correct ending on it via an accurately adjudicated claim/payment – you’re speaking our language. If you thrive in a fast-paced, dynamic environment and are passionate about improving healthcare financial processes, this is the opportunity for you to make a meaningful impact.

Fenyx Health is a new and growing health insurance company. We know the normal, negative connotation about health insurance companies, and we strive to be different. Our product, a Medicare Advantage Medical Savings Account, helps with that differentiation – our role is to help support our members make their own healthy choices in coordination with the care team of their choosing. At our core, we may simply pay bills, but we see ourselves as stewards for our members and their providers.

Because we’re new, we don’t have all the processes, tools and answers defined just yet. But we want your help in building our path forward. We’re looking for a smart, curious self-starter who isn’t afraid to wear both “thinker” and “doer” hats. We’re poised to grow significantly over the next couple of years and are looking for an operational architect to help ensure our claims shop can support that growth. And, as we grow, so you do your career opportunities with us!

Responsibilities

• Lead and supervise the accurate, timely and compliant processing of the claims inventory across the entire claims lifecycle, from intake through resolution, plus audits, reopenings and appeals.
• Develop and implement metrics/KPIs, operational policies and desk-level policies/procedures and job aids to increase accuracy and efficiency. Develop and monitor operational metrics, dashboards and reporting to provide visibility into performance and emerging trends at the team and individual levels.
• Train, mentor and supervise the claims team resources. Document and provide feedback via 1:1 meetings, team meetings, annual performance reviews and performance improvement plans.
• Collaborate with internal teams to identify day-to-day risks, dependencies and opportunities for improvement. Facilitate collaborative discussion and coordination around operational issues and escalations.
• Participate in operational reviews and planning discussions to inform strategic planning, growth initiatives and scalability efforts. Ensure operational readiness for product/client/market market expansions.
• Communicate clearly and professionally with all internal and external constituents, fostering strong, trust-based working relationships.
• Promote proactive identification, mitigation and reporting of claims-related compliance and regulatory risks. Partner with compliance, quality, legal, finance and other stakeholders to ensure policies, procedures and controls align with CMS/Medicare Advantage program and state DOI standards.
• Support audit readiness and coordination for CMS program audits, state DOI audits and internal reviews.
• Stay updated on industry regulations, coding updates and payer policies to ensure ongoing compliance and best practices.

Education and Qualifications

• Five or more years of Medicare healthcare claims processing, adjusting and/or auditing experience.
• Three or more years of supervisory experience, preferably within a healthcare claims or operational role.
• Ability to function effectively in a start-up environment. This means digging in when encountering things that aren’t well-defined, keeping a positive attitude, adapting quickly to changes and not letting perfect be the enemy of good enough.
• Advanced knowledge and experience in processing Medicare claims, particularly in a manual and/or audit environment. This means deep and proven experience using Medicare’s medical policy (NCD, LCD and Billing and Coding Articles) documentation, reimbursement methodologies and fee schedules, claims processing manuals, benefit policy manuals and other online resources.
• Advanced knowledge of healthcare industry practice and regulations, including HIPAA, Medicare and Medicare Advantage guidelines.
• Strong computer skills, including advanced proficiency in Microsoft Office Suite/Google Workspace, particularly Excel/Sheets.
• Strong problem-solving skills to identify root causes of discrepancies and propose solutions.
• Exceptional attention to detail coupled with deep organizational and analytic skills.
• Ability to develop and lead a team with patience, honesty and integrity.

Join us in transforming our healthcare financial operations! We are dedicated to supporting your professional growth while fostering an energetic environment where your contributions truly matter. Your expertise can help positively impact the experiences of our members and their healthcare providers.

Pay: $80,000.00 - $110,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Experience:

• Medicare medical/benefit, claims and reimbursement policy: 3 years (Required)
• health claims processing, audit or management: 5 years (Required)

Work Location: Remote