Claims Manager

Job Summary The Claims Manager will lead the healthcare claims operations within the Correctional Health Care Division. The role oversees claims processing personnel and workflows to ensure timely, accurate, compliant, and cost‑effective adjudication of inpatient and outpatient claims, while providing operational leadership, staff development, quality assurance, compliance oversight, process improvement, reporting, and system optimization. Responsibilities Provide direct leadership and oversight of all claims processing functions and staff. Supervise, mentor, train, and evaluate claims staff and support personnel. Establish departmental goals, performance standards, and productivity expectations. Conduct performance evaluations and provide coaching and development opportunities. Assist with staffing needs, onboarding, workflow assignments, and departmental coverage. Foster a collaborative and service‑oriented team culture. Oversee all healthcare claims processing activities to ensure timely, accurate, and compliant adjudication. Monitor and manage claims inventory, turnaround times, quality metrics, and operational performance. Review and resolve escalated or highly complex claims issues. Ensure accurate claim adjudication through evaluation of supporting documentation, benefit calculations, payment approvals, and denial determinations. Oversee claims adjustments and resolve discrepancies. Monitor claims trends and identify opportunities to improve efficiency and reduce processing errors. Ensure proper claims repricing using Medicare and NJ Medicaid fee schedules and reimbursement methodologies. Review financial impact and reimbursement accuracy of processed claims. Negotiate provider discounts and assist in resolving payment disputes when necessary. Analyze claims costs and identify opportunities for cost savings and operational improvements. Ensure compliance with all organizational policies, HIPAA requirements, and applicable state and federal regulations. Maintain confidentiality and security of all protected health information (PHI). Support audit preparation and corrective action implementation as needed. Lead the development and enhancement of claims workflows and operational procedures. Collaborate with leadership and IT teams on claims software improvements and system optimization initiatives. Identify automation opportunities and implement best practices to improve efficiency and accuracy. Develop and maintain departmental policies and standard operating procedures. Create, review, and distribute operational and client‑facing reports. Analyze claims data, trends, and key performance indicators. Prepare reports supporting operational, financial, and strategic decision‑making. Monitor quality assurance metrics and implement process improvement initiatives. Maintain positive relationships with providers, clients, and internal departments. Respond to escalated inquiries and resolve concerns promptly and professionally. Serve as a departmental liaison for claims‑related matters. Qualifications Bachelor’s degree in Healthcare Administration, Business Administration, Finance, or related field preferred. Certified Billing and Coding Specialist (CBCS) certification preferred. Minimum of five years of healthcare claims processing experience. Minimum of two years of supervisory or leadership experience preferred. Experience with inpatient and outpatient healthcare claims required. Correctional healthcare experience preferred. Strong knowledge of Medicare and NJ Medicaid fee schedules and reimbursement methodologies. Proficiency in managing claims processing software and systems. Ability to analyze data, identify trends, and recommend improvements. Excellent leadership, communication, and interpersonal skills. Physical Demands While performing this job, employees are regularly required to stand, walk, and talk; use hands to handle tools; reach with hands and arms; climb or balance; sit and stoop; kneel, crouch, or crawl; and frequently lift up to 50 pounds. Employees must have good vision in close, distance, color, peripheral, and depth perception. #J-18808-Ljbffr