RCM Insurance Claims Manager

Summary  

The Claims Manager is responsible for overseeing the claims process for diagnostic laboratory services, including claim submission, claim follow-up, denial resolution, and accounts receivable management. This role involves managing the Claims team, working directly with billing vendors and internal stakeholders to develop and maintain effective claims workflows aligned with payer requirements. The Claims Manager is accountable for optimizing claims performance, improving operational efficiency, and maximizing reimbursement outcomes. 

Job Responsibilities 

• Lead and manage the claims process for diagnostic laboratory services from claim submission through final resolution, ensuring timely and accurate reimbursement.

• Oversee the review and resolution of denied, pending, and aging claims, ensuring thorough investigation and appropriate corrective action.

• Ensure claims are submitted and managed in accordance with payer requirements, billing guidelines, and regulatory standards.

• Partner with internal teams and external billing vendors to resolve complex claim issues and improve reimbursement outcomes.

• Monitor claims inventory, accounts receivable performance, and operational metrics to ensure service level expectations are achieved.

• Lead, coach, and develop the Claims team, setting clear performance expectations and driving accountability for productivity, quality, and reimbursement results.

• Analyze claims and denial trends, identify root causes, and implement process improvements to reduce preventable denials and enhance claim performance.

• Communicate effectively with payers, vendors, and internal stakeholders to resolve issues, provide updates, and support organizational objectives.

• Prepare regular reports on claims activities, operational performance, reimbursement trends, and team productivity for leadership.

• Coordinate system implementations, upgrades, and process improvements related to claims workflows and billing operations and oversee ongoing support and maintenance activities.

• Develop and maintain claims-related policies, procedures, training materials, and operational best practices.

• The job may have added responsibilities as assigned. All job duties must be performed in a manner that demonstrates the company's Leadership Attributes and supports the Mission & Values of the company.

People Manager 

• Yes

Education, Experience, and Skills 

• Bachelor’s degree in healthcare administration, business, finance, or equivalent experience in a related field.

• 5–7 years of experience in laboratory billing, insurance claims, or revenue cycle management, specifically leading claims operations preferred.

• Strong understanding of insurance claim processes, healthcare regulations, HIPAA, and compliance requirements.

• Strong critical thinking skills to identify root causes, resolve complex claim issues, and implement effective solutions.

• Advanced knowledge of payer requirements, claim adjudication processes, denial management, and reimbursement methodologies.

• Ability to think critically, work efficiently and responsibly in a collaborative environment with multiple work demands and short time frames.

• Excellent leadership, communication, and organizational skills.

• Ability to analyze data, identify trends, and implement operational improvements that enhance claims performance and reimbursement outcomes.

• Understanding of industry-specific policies and regulations, including HIPAA requirements and payer compliance standards preferred.

• Experience using Microsoft Office applications.

• Familiarity with AI tools and technologies and the ability to leverage them to improve productivity, data analysis, reporting, workflow efficiency, and operational decision-making.

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