Position Summary
Advanced MSO is seeking an experienced, results-driven Claims Manager to lead and oversee our claims operations. This role is responsible for ensuring claims are processed accurately, efficiently, and in compliance with all applicable healthcare regulations and payer requirements. The ideal candidate is a strong leader with extensive knowledge of medical claims processing, reimbursement methodologies, and insurance regulations who thrives in a fast-paced healthcare environment.
As a key member of the leadership team, the Claims Manager will work closely with internal departments, health plans, providers, and external vendors to improve operational performance, maximize reimbursement opportunities, and deliver exceptional service to our clients. This position offers the opportunity to lead process improvements, mentor a talented team, and contribute directly to the continued growth and success of Advanced MSO.
Key ResponsibilitiesClaims Operations
- Oversee the day-to-day operations of the claims department, ensuring timely, accurate, and compliant claims processing.
- Monitor key performance indicators (KPIs), including turnaround times, claim accuracy, productivity, quality metrics, and service level agreements.
- Develop and implement strategies to improve operational efficiency while reducing processing errors and claim denials.
- Ensure proper adjudication of claims according to payer contracts, regulatory guidelines, and company policies.
- Monitor department workload and allocate resources to meet organizational goals.
- Audit preparation and compliance
Leadership & Team Development
- Recruit, train, mentor, and supervise claims analysts, processors, and support staff.
- Foster a collaborative, accountable, and high-performing team culture.
- Conduct regular performance evaluations and provide coaching for continuous professional development.
- Develop departmental goals and ensure team members consistently meet performance expectations.
- Promote employee engagement and encourage continuous learning and career growth.
Complex Claims Management
- Review, investigate, and resolve high-dollar, complex, or disputed claims.
- Make informed financial decisions regarding claim settlements, adjustments, appeals, and reserve recommendations.
- Escalate critical issues when necessary while maintaining positive relationships with providers, payers, and clients.
- Partner with executive leadership to resolve sensitive operational matters.
Process Improvement & Innovation
- Analyze claims trends, denial patterns, and operational data to identify opportunities for improvement.
- Lead workflow optimization initiatives and support automation projects that increase efficiency and accuracy.
- Collaborate with leadership to implement best practices and continuously improve departmental performance.
- Utilize reporting and analytics to identify root causes and implement long-term solutions.
Compliance & Quality Assurance
- Maintain compliance with CMS regulations, HIPAA, Medicare, Medicaid, commercial payer requirements, and all applicable federal and state regulations.
- Develop and oversee internal auditing processes to ensure quality standards and regulatory compliance.
- Stay current on healthcare legislation, reimbursement policies, and payer updates.
- Ensure the department consistently exceeds internal quality and compliance standards.
Vendor & Cross-Department Collaboration
- Manage relationships with third-party vendors and claims-related partners.
- Work closely with Finance, Provider Relations, Credentialing, IT, Compliance, Contracting, and Executive Leadership to resolve operational issues and improve claims performance.
- Participate in strategic planning initiatives that support company growth and operational excellence.
- Build strong relationships with clients and health plans while maintaining exceptional customer service.
QualificationsEducation
- Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field preferred.
Experience
- Minimum of 5 years of progressive experience in healthcare claims management, insurance operations, or managed care.
- Previous supervisory or management experience required.
- Experience working with Medicare Advantage, Managed Care Organizations (MCOs), IPA/MSO environments, or health plans is highly preferred.
Technical Knowledge
- Strong understanding of medical billing, coding, reimbursement methodologies, and claims adjudication.
- Working knowledge of ICD-10, CPT, HCPCS, and healthcare claims processing systems.
- Experience interpreting payer contracts and resolving complex reimbursement issues.
- Advanced proficiency in Microsoft Excel and healthcare claims management software.
- Familiarity with reporting tools and operational performance metrics is preferred.
Skills & Competencies
- Exceptional leadership and team management abilities.
- Strong analytical, critical thinking, and decision-making skills.
- Excellent organizational and project management capabilities.
- Outstanding written and verbal communication skills.
- Ability to prioritize multiple projects in a fast-paced environment.
- High level of professionalism, integrity, and attention to detail.
- Strong customer service mindset with the ability to build lasting professional relationships.
Compensation & Benefits
Salary: $65,000 – $78,000 annually, based on experience and qualifications.
Advanced MSO offers a competitive compensation package, opportunities for professional growth, and the chance to make a meaningful impact within a growing healthcare organization dedicated to operational excellence, innovation, and exceptional client service.
- Competitive annual salary
- Paid Time Off (PTO)
- Paid Holidays
- Opportunities for professional development and career advancement
- Collaborative and supportive team environment
Why Join Advanced MSO?
At Advanced MSO, we believe exceptional healthcare starts with exceptional operations. Our team is committed to delivering high-quality administrative and claims management solutions that support providers, health plans, and the communities they serve.
We are looking for leaders who embrace innovation, value collaboration, and are passionate about building efficient systems that improve healthcare outcomes. If you're ready to make an impact, lead a talented team, and grow your career with an organization dedicated to excellence, we'd love to hear from you.
Pay: $65,000.00 - $78,000.00 per year
Work Location: Hybrid remote in El Centro, CA 92243
