Claims Manager

Job Description

Job Description

 

Role Title: Claims Manager

Reports to: Chief Operations Officer

Location: FL, GA, NJ

 

About Heathos

Heathos is transforming the healthcare insurance landscape through a connected, data-driven ecosystem that simplifies complexity and drives long-term success. Built on trust, innovation, and integrity, we provide technology, services, and insights that support agencies, carriers, and members at every stage. Our family of brands—FirstEnroll, AdminOne, and SonicMarketing—works together to streamline operations and deliver a seamless insurance experience.

Position Summary

Manages day-to-day claims operations and leads the claims team to ensure accurate, timely, and compliant adjudication while delivering consistent service to clients and members.

 

Key Responsibilities

• Manages the day-to-day operations of the claims department, ensuring claims are processed accurately, timely, and in accordance with plan provisions, client requirements, and service standards.
• Leads, coaches, and develops claims processors and customer service representatives who support members with claims-related questions; establishes performance expectations, provides ongoing feedback, and promotes a culture of accountability and continuous improvement.
• Monitors claims inventory, turnaround times, accuracy, productivity, and other key performance indicators, adjusting workflows and staffing priorities as needed to meet operational goals.
• Oversees claims quality assurance and audit activities, identifies trends or errors, and implements corrective actions, training, and process improvements.
• Serves as the primary escalation point for complex, high-dollar, or sensitive claims issues and ensures timely resolution, clear communication, and appropriate documentation.
• Ensures claims are adjudicated in accordance with plan documents, benefit structures, internal policies, and applicable regulatory requirements, including HIPAA, ERISA, and CMS requirements.
• Partners with Claims Implementation, Client Services, IT, Compliance, and other internal teams to support new client onboarding, benefit changes, system configuration, testing, and successful transitions to ongoing operations.
• Reviews claims workflows, policies, and procedures and recommends improvements, automation, and system enhancements that increase accuracy, efficiency, and scalability.
• Coordinates training and knowledge transfer for new hires, process changes, client-specific requirements, and system updates.
• Supports capacity planning and resource allocation to maintain appropriate coverage and service levels during periods of growth, implementation activity, or increased claims volume.
• Prepares and communicates regular reports on claims performance, quality, trends, risks, and operational priorities to leadership and other stakeholders.
• Maintains current claims procedures and documentation and supports internal, client, and regulatory audits as needed.

Key Skills and Competencies

• Strong knowledge of healthcare claims processing, adjudication, benefit structures, and claims operations within a TPA or health plan environment.
• Demonstrated people leadership skills, including coaching, performance management, workload prioritization, and team development.
• Strong analytical and problem-solving skills with the ability to interpret performance data, identify root causes, and implement effective solutions.
• Excellent communication and stakeholder management skills, with the ability to manage escalations and collaborate effectively across functions.

Qualifications and Experience

• Bachelor's degree in Healthcare Administration, Business, or a related field preferred; equivalent relevant experience will be considered.
• 5+ years of experience in healthcare claims processing, claims operations, or a related role, preferably within a TPA or health plan environment.
• 2+ years of experience leading or supervising claims professionals, including responsibility for performance, quality, and workload management.
• Strong understanding of healthcare claims adjudication, plan documents, benefit structures, and applicable regulatory requirements, including HIPAA, ERISA, and CMS requirements.
• Experience with claims administration systems, reporting, quality assurance, system testing, and process improvement; advanced Excel skills preferred.

Heathos is proud to be an equal opportunity and affirmative action employer. We are committed to building a workforce that is representative of the agencies, carriers, and members we serve, creating a culture of belonging, and providing an equal employment opportunity regardless of race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, criminal histories consistent with legal requirements, or any other basis protected by law. See also Know Your Rights: Workplace Discrimination is Illegal.

If you have a need that requires accommodation, please let us know here.

Heathos is a binational company and, in order to facilitate efficient collaboration and communication binationally, English proficiency is a requirement for all roles unless stated otherwise in the job posting.