Find & Apply For Claims Specialist / Adjuster / Examiner Jobs in Orange, Connecticut

, Job Summary The Claims Manager is responsible for leading and developing the Claims team to ensure the timely, accurate, compliant, and service-focused administration of health benefit claims. This position provides direction, instruction, and guidance to team members while supporting company values, achieving company goals, and advancing the company vision. The Claims Manager oversees claim production, accuracy, lag, plan interpretation, complex claim resolution, regulatory compliance, and continuous process improvement. Supervisory Responsibilities This position has 3-6 reports Reporting Structure This position reports to the Vice President of Operations Job Logisitics This position is hybrid, with 80-90% of work completed remotely. The Hours are 40-43 hours per week. Duties/Responsibilities Lead, manage, coach, and develop a team of claims analysts to ensure timely, accurate, and consistent claim processing. Develop strategies to increase productivity, reduce waste, improve claim turnaround time, and enhance service quality. Communicate goals, performance expectations, deadlines, compliance requirements, and operational priorities. Monitor and measure team production, claim lag, accuracy, quality, and other established performance metrics. Identify and carry out coaching, mentoring, counseling, performance management, or disciplinary action as appropriate. Oversee the review and resolution of complex, high-dollar, or escalated claims, including coverage and benefit applicability, payment accuracy, and potential fraud, waste, or abuse indicators. Interpret plan documents, benefit provisions, policies, and administrative guidelines, and collaborate with internal stakeholders on complex interpretation issues. Support fair and compliant claim resolutions and communicate with members, providers, clients, attorneys, vendors, and other stakeholders as appropriate. Ensure claims administration complies with applicable federal and state regulations, plan requirements, company policies, and established quality standards. Maintain and promote comprehensive, accurate documentation of claim files, medical records, correspondence, decisions, and compliance-related activity. Apply knowledge of medical terminology, ICD-10/ICD-9, CPT, HCPCS, Medicare guidelines, and medical billing practices when reviewing or supporting complex claim issues. Identify potential fraud, waste, abuse, billing irregularities, and other claim risk indicators and escalate or coordinate investigation as appropriate. Analyze claim trends and operational data to identify process inefficiencies, training needs, financial risk, and opportunities for continuous improvement. Implement and document new processes, procedures, controls, and best practices as needed. Collaborate with Operations, Client Services, Compliance, Stop Loss, Medical Management, vendors, and other business partners to resolve claim issues and improve outcomes. Provide management with creative and innovative ideas to improve operational performance, service, cost management, and revenue opportunities. Meet with team members individually and as a group to discuss successes, challenges, performance, development needs, and new goals. Oversee team scheduling and staffing to meet company and client needs and recommend overtime to management as needed. Maintain current knowledge of changes in healthcare claims administration, medical coding, Medicare guidance, regulatory requirements, and industry best practices through continued professional learning. Exercise critical, independent judgment and sound decision-making to reach solution-based outcomes while managing multiple competing priorities and tight deadlines. Work 40-42 hours per week, generally during the core business hours of 8:00 a.m. to 5:00 p.m., with additional hours as necessary for special projects or deadlines. Meet outlined expectations and goals. Occasionally attend Company-sponsored events or off-site health fairs before, during, or after normal business hours.

Pay:

$65,000.00 - $75,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Paid time off Paid training Vision insurance Work from home

Work Location:

Hybrid remote in Orange, CT 06477