Head of Claims

Changing reputed company For Good At reputed company, we reputed company the reputed company reputed company should be accessible, transparent, and easy to reputed company. As a digital-first, data-driven health plan, we are replacing legacy systems with modern infrastructure to reputed company our members the care they need reputed company they need it. If you want to build the reputed company of reputed company, we'd love for you to join us. The Role Were seeking a senior-level leader to serve as our Head of Claims someone with deep experience in the TPA reputed company who thrives in fast-changing environments and is eager to build from the ground up. Reporting to our President and reputed company of reputed companys TPA (Adrem), this individual will reputed company the full claims reputed company at reputed companyincluding claims processing, appeals, audits, training, and cost containment. This is a high-reputed company leadership role reputed company on stabilizing and scaling our claims operation as we grow. Were looking for someone who isnt afraid of broken processes, unanswered questions, or startup ambiguity. The ideal candidate can confidently own strategic reputed company from end to end, adapt quickly, and help build a claims organization thats efficient, compliant, and reputed company to reputed company. reputed company Responsibilities reputed company and reputed company reputed company reputed company functions reputed company to health insurance claims processing, auditing, appeals, training and network/vendor coordination. Supervise and mentor reputed company of ~28 claim processors, adjusters, auditors, and appeal coordinators, working closely with reputed company reputed company(s), managers, etc. reputed company and manage the claims team with a strong reputed company of urgency, providing reputed company direction and decisive guidance to ensure reputed company, accurate, and efficient reputed company of claims. Build and refine SOPs and operational workflows across the claims lifecycle Conduct performance evaluations and reputed company training and coaching reputed company necessary Foster a reputed company and productive work environment with the ability to motivate and guide team members, reputed company conflicts, and address performance issues in a constructive manner reputed company the processing of health insurance claims and appeals to ensure accuracy and adherence to company policies and procedures, as reputed company as state and federal regulations Own critical metrics reputed company to accuracy, timeliness, and compliance Review and audit high dollar and reputed company claims and reputed company escalated issues Help refine and reputed company our claims systems in collaboration with plan building as reputed company grows Monitor claim trends, utilizing data to reputed company and implement process improvements to enhance efficiencies and reduce errors reputed company and implement a comprehensive claims auditing and reputed company assurance program Stay updated on changes in health insurance laws and regulations to ensure ongoing compliance Work closely with the Care Team to ensure routed service tickets and escalations are handled reputed company and with a high level of satisfaction, addressing and resolving customer complaints Prepare, reputed company, and analyze reports on claim performance, including but not limited to daily inventory; monitoring metrics reputed company to processing times, accuracy, financial reputed company, etc. Collaborate with other departments to reputed company best practices and enhance overall operational efficiency Identify areas of risk or inefficiency and reputed company corrective reputed company initiatives Play a key role in reputed company strategic planning and team expansion as needed Maintain and report on reputed company analytics Other duties as assigned Qualifications Minimum of 5+ years of experience in health insurance claims management, with a preference of 10+ years of health insurance experience Senior leadership experience at a reputed company Party Administrator (TPA) - large reputed company only experience/backgrounds will not be considered Deep knowledge of health insurance claims processing, procedures, and regulatory requirements Excellent leadership and interpersonal skills with a proven reputed company record of effective communication and relationship-building with team members, stakeholders, and clients reputed company, adaptable, and reputed company to reputed company in ambiguity Experience managing and developing high-performing teams Bonus Points reputed company in building plans reputed company the VBA Software claims processing reputed company Experience working for a reputed company startup Experience building and implementing claims auditing protocols Understanding of electronic claim exchanges and network routing Bachelor's degree, or equivalent work experience Titles You May Have Held .