Claims Processing and Quality Manager

The Claims Processing and Quality Manager oversees the daily operations of the claims department, ensuring claims are processed accurately, efficiently, and in compliance with company policies and regulatory requirements. This role provides leadership, guidance, and technical support to claims staff while driving workflow efficiency, quality assurance, and continuous improvement. Manager of Claims Processing and Quality has a focus on direct member reimbursement processing and tracking, Medicare/Medicaid subrogation claims processing and new client implementation testing. Must report on site 5 days a weekKey ResponsibilitiesClaims Operations ManagementOversee day-to-day claims processing to ensure accuracy, efficiency, and compliance with regulations and internal policiesMonitor claims inventory, assignments, and turnaround times to meet departmental service goalsOversee the resolution of complex claims issues and act as the primary escalation pointPerform 2nd set of eyes on DMR claims processed by Claims ProcessorsTimely address DMR related questions from other internal departmentsNew Client Implementations Testing ManagementOversee end-to-end implementations testing for new client builds, including test case development, scenario creation, and validation of adjudication outcomesEnsure all claims testing aligns with client contracts, benefit summaries, regulatory requirements, and organizational standardEnsure testing environments accurately reflect production design and escalate discrepancies as neededMedicare/Medicaid Subrogation ManagementOversee Medicare and Medicaid subrogation claim processing to ensure compliance with state and federal recovery requirementsPartner with internal and external stakeholders to support accurate investigation, documentation, and recovery effortsStaff ManagementOversee daily scheduling and assignment of employee tasks to ensure balanced workloads and operational efficiency.Manage employee PTO requests and oversee payroll processesConduct interviews and participate in the selection process for open departmental positionsFacilitate departmental, cross-departmental, and individual employee meetings to support communication and alignmentDevelop, update, and maintain process documentation, desktop procedures, and operational frameworkQualifications:Required3+ years of experience in claims processing or a related insurance fieldAt least 2 years in a supervisory or leadership roleAbility to work in a fast-paced environment with shifting priorities.Strong Microsoft Excel skillsMinimum of 12 months of prior claims processing experience and PBM terminologyPreferredStrong leadership and team management skills with the ability to coach, train, and motivate staffProblem-solving ability to investigate missing information or discrepanciesOrganizational skills for managing workloadStrong understanding of PBM operations.Featured BenefitsCompetitive salaryPotential to earn $1,000 sign-on bonusVacation and Sick/Personal TimeMedical InsuranceHearing Program DiscountShort- & Long-Term Disability InsuranceLife InsuranceFlexible Spending Account401(k)Employee Referral ProgramEmployee RecognitionTuition ReimbursementProfessional Development TrainingAbout Benecard Services our affiliated companies:Benecard Services, LLCBenecard Services, LLC has been administering carve-out, fixed rate insured prescription drug benefit programs since 1990. Benecard is a full service, in-house prescription benefit administrator that includes mail and specialty drug dispensing. We are a premiere nationwide Prescription Benefit Administrator headquartered in Lawrenceville, New Jersey.Website: http://www.benecard.comBeneCard PBFBeneCard PBF provides self-funded prescription benefit program administration with a personalized approach through focused, clinical expertise. Our business model operates on a customized claim processing system offering unlimited capability and flexibility to respond to client needs in an evolving marketplace. Advanced clinical programs and advanced technology provide the framework to maximize the use of all data elements available. This allows BeneCard PBF to filter the information, focus on clinical opportunities and facilitate interaction between the physician, the pharmacist and the patient to effectively promote complete health care. Headquartered in Bonita Springs, Florida.Website: http://benecardpbf.comNational Vision AdministratorsFor over 40 years, National Vision Administrators (NVA) has been meeting the vision benefit needs of public employer groups, Health & Welfare Funds, Associations and Coalitions. Providing millions of people throughout the United States with vision care programs that help them be smarter buyers of eye care and eyewear, NVA is particularly well suited to address today's health benefit challenges as it relates to eye care. We offer cost-effective, customized vision benefit programs that are clinically integrated. We are proud of the fact that we have retained over 99% of our clients and believe it is the greatest testimony to the high-quality benefits and service satisfaction we provide to both our clients and their members. Headquartered in Clifton, New Jersey.Website: http://www.e-nva.com