Senior Manager, Claims Operations

Senior Manager, Claims Operations

We are seeking an experienced Senior Manager, Claims Operations to lead and strengthen our claims function and help build the processes, controls, reporting, and technology infrastructure necessary to support our continued growth.

Position Summary

The Senior Manager, Claims Operations will have primary responsibility for overseeing MediDrive's end-to-end claims operations, including claims submission, adjudication, reconciliation, encounter reporting, remittance processing, provider payment support, and claims-related financial reporting.  This individual will work closely with Operations, Finance, Accounting, Product, Technology, and our healthcare clients to ensure claims are processed accurately, reconciled completely, and reported appropriately.

A critical component of this position will be the ability to understand and manage 835 remittance files, 837 claims/encounter transactions, Medicaid encounter reporting, Medical Loss Ratio (MLR) reporting, and transportation-related claims and provider payments.

This is a hands-on leadership role. The successful candidate will not only manage existing claims processes but will also identify gaps, develop solutions, establish controls and KPIs, and help create a scalable claims operating model as MediDrive continues to grow.

Key Responsibilities

Claims Operations & Management

• Lead the day-to-day operation of the claims function and oversee the complete claims lifecycle from initial submission through adjudication, payment, denial, adjustment, and final reconciliation.
• Develop and maintain scalable claims workflows, policies, procedures, and internal controls.
• Monitor claims volumes, payment activity, outstanding claims, denials, rejections, adjustments, and exceptions.
• Identify duplicate, rejected, incorrectly processed, or unresolved claims and drive issues through resolution.
• Establish claims aging and exception-management processes to ensure outstanding items are identified and resolved timely.
• Ensure claims operations comply with applicable contractual, client, Medicaid, and regulatory requirements.

835 / 837 & Encounter Management

• Oversee the processing, validation, and reconciliation of 835 Electronic Remittance Advice (ERA) files.
• Manage and understand 837 healthcare claims and encounter transactions, including submission, acceptance, rejection, and reconciliation.
• Oversee Medicaid encounter reporting and ensure submitted encounter data is complete, accurate, and reconciled to underlying claims and transportation activity.
• Work closely with Technology and Product teams to identify and resolve EDI, data, claims-processing, and system integration issues.
• Develop controls to ensure claims and encounter files are successfully transmitted, accepted, and appropriately reflected in downstream financial and operational systems.

Medical Loss Ratio (MLR) & Financial Reconciliation

• Partner with Finance and Accounting to support accurate and timely Medical Loss Ratio (MLR) reporting and analysis.
• Reconcile claims and transportation expenses to client funding, provider payments, remittance activity, and financial reporting.
• Assist Finance with month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and other claims-related accounting requirements.
• Provide visibility into claims trends and cost drivers that may impact client profitability and MLR performance.
• Ensure appropriate reconciliation between operational claims systems and the General Ledger.

Transportation Provider Payments

• Oversee claims-related processes supporting payments to transportation providers.
• Develop controls to ensure transportation providers are paid accurately and only for properly validated and approved transportation services.
• Reconcile provider payments to underlying trip and claims data.
• Partner with Finance and Operations on provider payment processes, including payments made through RAMP or similar payment platforms.
• Identify payment discrepancies, duplicate payments, missing payments, and other exceptions and ensure timely resolution.

Reporting, Analytics & Controls

• Develop and maintain claims dashboards, KPIs, and management reporting, including:
  • Claims submitted, accepted, rejected, and paid
  • Claims aging
  • Denials and rejection rates
  • Payment turnaround times
  • Outstanding and unresolved claims
  • Encounter submission and acceptance rates
  • Provider payment reconciliations
  • MLR and claims cost trends
• Establish measurable service levels and performance standards for the claims function.
• Provide senior management with clear visibility into claims performance, financial exposure, operational risks, and emerging trends.
• Continuously evaluate claims processes and identify opportunities for automation, improved controls, and increased efficiency.

Cross-Functional Leadership

• Serve as a key liaison between Claims, Finance, Accounting, Operations, Product, Technology, and Compliance.
• Partner with Product and Technology teams to help design and enhance MediDrive's claims technology infrastructure.
• Work directly with healthcare clients and internal stakeholders to resolve claims, encounter, reconciliation, and reporting issues.
• Support audits, client reviews, and requests for claims-related documentation.
• Help build and develop the Claims team as MediDrive's transaction volumes and client base continue to grow.

Qualifications

Required

• Bachelor's degree in healthcare administration, finance, accounting, business, information systems, or a related field, or equivalent relevant professional experience.
• 5+ years of healthcare claims operations experience, with demonstrated responsibility for high-volume claims processing, reconciliation, or payment operations.
• Strong hands-on experience with 835 remittance files and 837 claims/encounter transactions.
• Experience with Medicaid, managed care, health plans, TPA operations, NEMT, or another healthcare claims environment.
• Experience supporting or analyzing Medical Loss Ratio (MLR) calculations and claims cost reporting.
• Strong understanding of claims adjudication, denials, adjustments, reconciliation, and encounter reporting.
• Experience developing claims controls, reconciliations, dashboards, KPIs, and management reporting.
• Strong analytical skills with the ability to identify discrepancies across large volumes of claims and payment data.
• Ability to work effectively across Finance, Accounting, Operations, Product, Technology, and Compliance functions.

Strongly Preferred

• Direct experience within Non-Emergency Medical Transportation (NEMT), transportation benefits, or healthcare transportation.
• Experience with Medicaid transportation claims and encounter reporting.
• Experience reconciling transportation provider payments to claims and trip-level data.
• Familiarity with RAMP or similar provider/payment platforms.
• Experience helping build or scale a claims operation within a rapidly growing organization.
• Experience working with claims technology, EDI platforms, or claims management systems.
• Advanced Excel and data analysis skills.

What We Are Looking For

The ideal candidate is a hands-on claims leader who understands both the operational and financial sides of healthcare claims. This person should be equally comfortable reviewing an 835 or 837 file, investigating a claims reconciliation discrepancy, analyzing MLR performance, working with a technology team on a claims workflow, and explaining claims trends to senior leadership.  We are looking for someone who is highly organized, analytical, detail-oriented, and comfortable operating in a fast-growing environment where processes are continually being developed and improved. Most importantly, this individual should have the ability to take ownership of the claims function and help build a scalable infrastructure capable of supporting MediDrive's continued national growth.

Compensation

The anticipated base salary range for this full-time position is $100,000–$110,000 annually, depending on experience and qualifications.

This is a full-time remote position within the United States.