Sr. Manager of Medical Claims - TPA

Overview

Who We Are

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Learn even more about the work that drives us at personifyhealth.com.

Responsibilities

Ready to own the engine that keeps our members protected — and make it run better every day?

Why This Role Matters

 

Claims operations sit at the center of everything we promise our clients and members. When complex, high-dollar, or high-risk claims move through the system accurately and on time, trust is built — and when they don't, it erodes fast. As Senior Manager of Claims, you're the person who makes sure that doesn't happen. You'll lead a team of claims examiners, drive process improvements, and partner across the organization to eliminate inefficiencies and strengthen compliance. The quality of your work shows up directly in client satisfaction, regulatory standing, and the operational credibility of Personify Health.

 

Work Location: This is an on-site role based in Tempe, AZ. Candidates must be available to work from the office on a full-time basis.

 

What You'll Actually Do

• Lead and develop a claims team: Coach, guide, and hold accountable a team of examiners handling high-risk and complex claims — driving performance, engagement, and results through active feedback and talent development.
• Own complex and high-risk claims resolution: Oversee pended, high-dollar, and special-handling cases from start to finish, ensuring timely, accurate adjudication that meets established policies and service standards.
• Resolve escalated issues and payment discrepancies: Troubleshoot claim payment problems and partner with internal teams on fraud investigations, escalated inquiries, and other high-stakes situations.
• Manage regulatory and legal response: Coordinate responses to audits, legal requests, insurance complaints, Department of Labor matters, and regulatory inquiries — keeping documentation tight and timelines met.
• Drive compliance across the operation: Ensure adherence to Medicare, HIPAA, and applicable regulatory standards, conducting ongoing reviews to maintain quality, productivity, and documentation requirements.
• Identify and fix operational inefficiencies: Pinpoint workflow gaps, standardize procedures, implement best practices, and partner with leadership to increase auto-adjudication rates and reduce manual intervention.
• Collaborate cross-functionally on system and process improvements: Work with IT, legal, compliance, and vendors to support system enhancements, test and implement updates, and optimize EDI processes.
• Monitor KPIs and surface actionable insights: Track accuracy, productivity, and turnaround metrics to spot trends, root causes, and improvement opportunities — then translate findings into clear recommendations for leadership.
• Support new business and growth initiatives: Contribute to implementations, RFP support, and project teams, providing operational expertise to resolve challenges and ensure successful launches.

 

 

Qualifications

What You Bring to Our Team

 

Education & Experience:

• Bachelor's degree in Business Administration, Health Administration, or a related field preferred
• 7+ years of experience in claims operations, preferably within a TPA environment
• 5+ years of leadership or supervisory experience in claims management

Technical Skills:

• Deep knowledge of claims processing systems, workflows, and regulatory requirements (Medicare, HIPAA, DOL)
• Experience with electronic data interchange (EDI) processes and claims adjudication platforms
• Proficiency in KPI analysis, reporting, and process improvement methodologies
• Familiarity with audit response processes, compliance documentation, and legal/regulatory coordination

 

Benefits

 

The Highlights:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Unlimited P