Claims Manager (Clearwater Beach)

Claims Manager Servicing Health Insurance Policies Or Benefits

Summary : Premier Administrative Solutions (PAS) is a Third-Party Administrator (TPA) which provides a wide range of administrative services to insurance companies, sharing organizations, insurance marketing organizations, and employers. One core service, claims administration, is where submissions for payment / reimbursement / sharing from medical providers and covered individuals are reviewed, subject to cost controls and ultimately adjudicated, resulting in an explanation of handling to the submitter.

This service is provided subject to service level agreements which mandate a high level of service measured by timely turnaround and a high degree of accuracy. Accuracy is measured by adherence to all written procedures and controls applicable to claims as well as the client's stated coverage.

Join Premier Administrative Solutions as a Claims Manager and lead our Claims Department in delivering exceptional service to insurance companies, employers, and members. In this pivotal role, you'll oversee claims adjudication, drive operational strategy, and ensure high accuracy and timely service per our service level agreements. You'll manage relationships with vendors, spearhead quality improvements, and foster a culture of transparency and member-focused service. With at least 5-7 years of claims operations management experience and strong leadership skills, you'll shape department success through budgeting, staffing, and innovative automation strategies. If you're ready to make a meaningful impact in a dynamic third-party administration environment, this is your opportunity to shine.

Responsibilities

Essential Duties And Responsibilities :

Participating actively as a key member of the PAS' Management Team, including demonstrating leadership through strong communications skills, use of business metrics to determine strategy and resource needs, and showing a high level of focus on continual quality improvement.

Coordination of all activities of the Claims Department Management Team. This includes Supervisors and / or Team Leaders assigned to PAS' Customers.

Responsibility for Claims Department strategy, planning, staffing projection, budgeting and quality assurance and improvement.

Responsibility for final hiring decisions on employees within the Claims Department. This is to ensure that high standards are maintained, and compensation arrangements are discussed and approved by Human Resources and the Chief Operating Officer of PAS.

Creating a culture within the Claims Department of exceptional service to members and their providers, as well as transparency in reporting results, trends and issues to Senior Management and clients.

Management of relationships with Preferred Provider Organizations and Reference-Based Pricing vendors which are essential to managing the cost of claims for clients.

Management of relationships with essential vendors involved with the Claims Adjudication process, including clearinghouses, claims cost control vendors and the claims fulfillment vendor (printing and mailing of checks and EOP / EOB, as well as electronic payments).

Identification and management of Subject Matter Experts (SMEs), with back-ups in various aspects of Claims, including procedures and use of technology.

Oversight of Claims Training programs, including training for new employees and ongoing reinforcement training.

Oversight of Claims documentation, including Policies and Procedures and reference materials.

Participates in RFP / Proposal processes, including participation when requested in prospective client presentations.

Essential Duties Specific To Claims Department :

Participation in product development, including the technical review of new products and prospective new clients. This assistance will be focused on evaluation and interpretation of benefits, advancements in health care requiring updates to programs and plans, and advancements in administration, including use of AI.

Ensuring that daily reporting provides an accurate portrayal of claims on hand, including those received by the clearinghouse, sent to re-pricing entities, unable to be systematically matched, auto-adjudicated, in Examiner queues waiting to be adjudicated, and in either audit or needing approval status.

Developing and implementing strategies for greater automation in the claims process, including electronic receipt of claims and auto-adjudication.

Establishing production requirements for Examiners, and along with the Supervisor monitoring performance against the requirements.

Establishing and monitoring strong operational controls relating to claims cost control, including review processes for potential pre-existing conditions, determining medical necessity, enforcing reasonable charge provisions and pursuing recovery of third-party liability.

Monitoring and continually developing Policies and Procedures intended to enforce consistency in process and improve quality.

Working with the Manager of Quality to implement appropriate standards for accuracy and audit procedures intended to validate those standards are met. This includes setting release authority levels and random audit percentages for Examiners reflecting experience and historical quality results. It will also include development of coaching and training programs linked to emerging quality issues.

Using audit results to develop ongoing training programs and new procedures intended to increase procedural, payment and financial accuracy percentages.

Coordinating escalations from other Departments with the Claims Supervisor to ensure that timely and complete actions and responses are provided.

Reviewing and approving higher dollar claims prior to payment.

Oversight for the ongoing management of claims processing technology, including plan building and identification of new and updated benefit categories based on new medical coding and medical services.

Act as a liaison with clients for escalation of service issues or program questions, establishing a strong working relationship and client trust.

Investigates and participates in formal responses relating to complaints, grievances and appeals received by or applicable to PAS.

Participates in Product Development and Sales processes, including participation when requested in prospective client presentations, regulatory reviews and contracting of vendors.

Primary Performance Expectations : Performance review for the Claims Manager is ongoing, with formalized reviews quarterly. There will be an Annual Review completed each January which will determine adjustments to compensation, and availability of incentive compensation. Performance expectations or goals are as follows :

Budget PerformanceThe Claims Manager will be evaluated based on the level of variance with the budget established for the Claims Department, measured by staffing and other expenses. Operating expenses for the Claims Department will be measured by total per household per month (PHPM) and per inbound claim cost so that improvements in productivity and efficiency are rewarded.

Department Results for Service Level AgreementsSLA results will be measured quarterly and reported specifically by client.Department Satisfaction LevelAn annual Satisfaction Survey will be provided to the relationship manager for each PAS client where Claims services are provided. The Departments will be graded in total and by Team, and in each case must be graded with a score of at least 4 out of 5 (Highly Satisfied).Department Quality LevelThe Department will be audited by Enterprise Risk Management (ERM). Actual results will be compared to goals in each period.

Qualifications

Qualifications And Competencies :

A minimum of at least 5-7 years in a Management role for Claims Operations, servicing health insurance policies or benefits.

Strong organizational, interpersonal and motivational skills.

Excellent written and verbal communication skills.

A college degree is preferred.

Environmental Factors / Physical Demands : Work is performed in an office. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.

Join us and enjoy a robust benefits package designed to support your well-being! Full Time employees can enjoy :

Health Coverage : Two flexible medical plans

Dental & Vision : Comprehensive coverage. Vision is company paid

Health Savings Account (HSA) : Pre-tax contribution

Flexible Spending Accounts (FSA) : Medical and Dependent Care option

Life & Disability Insurance : Company-paid, with optional additional coverage

Generous Paid Time Off (PTO), plus additional paid holiday

Employee Assistance Program (EAP) : Wellness support

401k Retirement Plan : Participate and receive a company match after meeting eligibility requirements

Frequent and ongoing employee appreciation and celebration throughout the company

Dynamic, challenging, and motivating work environment

Clear career path and opportunities for growth

VERY competitive pay and compensation package

Outstanding employee retention rate

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