Manager, Claims Processing

The Manager, Claims Processing reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Manager, Claims Processing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals. The Manager, Claims Processing is responsible for leading and overseeing the end-to-end claims adjudication and processing function for a TPA organization. This role manages professional and/or supervisory-level associates and ensures timely, accurate, and compliant processing of complex and specialty home health, DME, home infusion and SNF claims submitted via electronic and paper formats. The Manager applies advanced technical and regulatory knowledge of Medicare, Medicaid, and commercial payers to resolve moderately complex claims issues, optimize workflows, and improve departmental performance. Responsibilities are executed within established policies and practices, with a planning horizon of less than 24 months. Key Responsibilities Claims Operations & Adjudication Oversee the review, adjudication, and resolution of home health, DME, home infusion and SNF claims, including Medicare, Medicaid, and commercial payer claims, ensuring compliance with payer guidelines, CMS regulations, and organizational policies. Determine whether claims are paid, denied, returned, or adjusted based on clinical documentation, coding accuracy, authorization status, and payer requirements. Manage escalated, complex, or high‑risk claims issues, including denials, underpayments, and payer disputes. Leadership & People Management Manage and develop claims processing professionals and/or claims supervisors; set performance expectations, provide coaching, and conduct performance reviews. Coordinate team activities to ensure department goals, productivity metrics, accuracy standards, and service‑level agreements are met. Identify staffing, training, and resource needs; make tactical decisions related to workload distribution and prioritization. Process Improvement & Decision Making Identify, lead, and implement change initiatives to improve claims processing efficiency, denial rates, turnaround times, and cash flow. Analyze claims trends, denial patterns, and payer policies; partner with Revenue Cycle, Clinical, Compliance, and Authorization teams to address root causes. Use advanced analysis and independent judgment to solve moderately complex operational and technical problems within established policies. Cross‑Functional Collaboration Collaborate with Coding, Clinical Operations, Intake, Authorization, Finance, and Compliance teams to ensure accurate documentation and clean claim submission. Maintain frequent contact with peer managers and senior professionals across departments to align on workflows, regulatory updates, and payer changes. Participate in cross‑department meetings, briefings, and audits related to billing and claims performance. Compliance, Reporting & Oversight Ensure adherence to Medicare Conditions of Participation (CoPs), CMS Claims Processing Manual guidance, HIPAA, and payer‑specific rules. Support internal and external audits by maintaining accurate documentation and providing claims data and analyses as requested. Monitor KPIs such as days in A/P, first‑pass yield, denial rates, and rework volume; report results to department leadership. Autonomy, Decision Making & Impact (M2 Alignment) Exercises independent judgment within defined policies to determine operational approaches, resource allocation, and workflow priorities for the claims team. Decisions have a moderate impact on departmental performance, revenue cycle outcomes, and payer compliance. Works with a planning horizon of up to 24 months, focusing on continuous improvement and operational stability. Holds significant influence over claims processing operations and contributes to broader revenue cycle effectiveness. Work Complexity & Knowledge Applies in‑depth knowledge of home health, DME, home infusion and SNF billing, claims adjudication, reimbursement methodologies, and payer regulations. Solves moderately complex claims and operational issues using advanced technical expertise, analytical skills, and cross‑functional collaboration. Communicates effectively with internal stakeholders and external payer representatives to resolve issues and drive outcomes. Required Qualifications Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field, or equivalent combination of education and experience. 5+ years of progressive experience in claims processing, billing, or revenue cycle management within home health, DME, home infusion, SNF or related healthcare settings. 2 or more years of people management experience. Comprehensive knowledge of all Microsoft Office applications, including Word, Project and Visio. Strong working knowledge of Medicare, Medicaid, and commercial insurance reimbursement, EDI claims, and healthcare billing systems. Must be passionate about contributing to an organization focused on continuously improving consumer experiences. Preferred Qualifications Project Management experience. Six Sigma certification. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $78,400 - $107,800 per year. This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description Of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole‑person well‑being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short‑term and long‑term disability, life insurance and many other opportunities. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. #J-18808-Ljbffr