Claims Manager

Located in Clearwater, FL

Claims Manager

?? Clearwater, FL | On-Site | Full-Time | Exempt

Seeking an experienced Claims Manager to lead and optimize health insurance claims operations. This role is ideal for a strategic, detail-oriented leader who excels in accuracy, compliance, process improvement, and team development.

 

Position Summary

The Claims Manager oversees daily claims operations, ensuring timely turnaround, strict accuracy standards, regulatory compliance, and high-quality service delivery. This position also plays a key role in process development, automation initiatives, and cross-department collaboration.

 

Key Responsibilities

Operational Leadership

• Lead and support Claims Supervisors/Team Leads and departmental staff.
• Drive departmental strategy, staffing projections, workflow design, and budgeting.
• Maintain a culture centered on accuracy, quality, service excellence, and transparency.

Claims Oversight

• Oversee daily reporting for all claims in process, including clearinghouse activity, auto-adjudication, audits, and approvals.
• Develop and refine automation strategies to improve efficiency and reduce manual handling.
• Implement strong operational controls related to medical necessity review, reasonable charge enforcement, pre-existing conditions, and third-party liability recovery.

Quality, Procedures & Training

• Establish and enforce Policies & Procedures to maintain consistency and compliance.
• Partner with Quality teams to set audit standards, accuracy goals, and release authority levels.
• Use audit findings to build coaching, corrective actions, and ongoing training programs.
• Oversee documentation, training materials, and new employee onboarding.

Cross-Department & Client Support

• Serve as an escalation point for internal teams and external partners.
• Participate in product development, new client evaluations, and client presentations when needed.
• Support responses to appeals, grievances, and escalated service issues.
• Manage relationships with network vendors, repricers, clearinghouses, and fulfillment vendors.

 

Performance Expectations

• Meet or exceed departmental SLAs for turnaround time, accuracy, and quality.
• Maintain client satisfaction scores of at least 4/5.
• Operate within budget targets for staffing and operational costs.
• Demonstrate improvements in productivity, workflow efficiency, and claim accuracy.

Qualifications

Required

• 5–7+ years of Claims Operations Management experience in health benefits/insurance.
• Third-Party Administrator (TPA) experience required.
• Strong understanding of automated claims adjudication systems.
• Experience with network repricing, PPO relationships, and cost-containment strategies.
• Strong communication skills and leadership ability.
• Highly organized, analytical, and process-focused.

Preferred

• Bachelor’s degree.
• Familiarity with EHR systems, CRM platforms, benefit administration software, and databases.
• PMP, CEBS, or similar certifications.

 

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