Claims Manager

Job Summary

The Claims Manager is responsible for the overall leadership, management, and strategic oversight of all healthcare claims operations within the Correctional Health Care Division. This position oversees claims processing personnel and workflows to ensure timely, accurate, compliant, and cost-effective adjudication of inpatient and outpatient healthcare claims. The Claims Manager provides operational leadership, staff development, quality assurance, compliance oversight, process improvement, reporting, and claims systems optimization while ensuring adherence to healthcare regulations and organizational standards.

This role serves as the primary resource for claims operations and collaborates with internal departments, providers, and leadership to support efficient and effective claims administration.

Essential Duties and Responsibilities

Leadership & Staff Management

• Provide direct leadership and oversight of all claims processing functions and staff.
• Supervise, mentor, train, and evaluate Claims Processors, Lead Claims Processors, 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.
• Other duties as assigned

Claims Operations Management

• 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 resolution of discrepancies.
• Monitor claims trends and identify opportunities to improve efficiency and reduce processing errors.

Repricing & Financial Oversight

• Ensure proper claims repricing utilizing Medicare and New Jersey 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.

Compliance & Regulatory Oversight

• Ensure compliance with all organizational policies, HIPAA requirements, and applicable state and federal insurance regulations.
• Remain current on regulatory updates, DRGs, billing codes, reimbursement methodologies, and claims processing requirements.
• Ensure confidentiality and security of all protected health information (PHI).
• Support audit preparation and corrective action implementation as needed.

Process Improvement & Systems Optimization

• 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.

Reporting & Data Analysis

• 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.

Customer Service & Collaboration

• 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.

Organizational Expectations

• Provides a positive and professional representation of CFG Health Systems, LLC.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope of job role or practice
• Adheres to infection control policies and protocols, medication administration and storage procedures, and controlled substance regulations
• Participate in ongoing quality improvement activities
• Completes required orientation as directed by the facility
• Follows facility and OSHA safety rules and procedures while on assignment
• Follows facility and CFG Health Systems Occurrence Protocol
• Upholds HIPAA and PREA regulations
• Punctual and dependable for assigned/confirmed shifts
• Maintains security clearance for the assigned facility

Education and Experience

• Bachelor’s degree in Healthcare Administration, Business Administration, Finance, or related field preferred.
• Certified Billing and Coding Specialist (CBCS) certification preferred.
• Minimum of five (5) years of healthcare claims processing experience.
• Minimum of two (2) years of supervisory or leadership experience preferred.
• Experience with inpatient and outpatient healthcare claims required.
• Correctional healthcare experience preferred.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, walk, and talk or hear. The employee frequently is required to use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; and climb or balance. The employee is occasionally required to sit and stoop, kneel, crouch, or crawl. The employees must frequently lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.