Manager, Member Claims

At Collective Health, we’re transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology, compassionate service, and world-class user experience design.

This role oversees the Member Claims General Processing Teams, responsible for the day-to-day processing and adjudication of medical claims. These teams play a vital role in ensuring the accuracy, timeliness, and efficiency of claims processing for our employer-sponsored medical plans while addressing complex claims scenarios and maintaining compliance with regulatory and operational requirements.

Key responsibilities of the Member Claims General Teams include:

• Accurate and timely adjudication of medical claims.
• Conducting in-depth research and resolution of claims issues.
• Managing the intricate details of regulatory requirements, network partner relationships, and benefit application.
• Supporting seamless claims operations through efficient and effective workflows.

As the Manager of Member Claims (General Claims Teams), you will lead these essential teams, driving their performance to achieve key metrics and ensuring operational excellence. Your role will include:

• Setting team goals and fostering a high-performing, collaborative culture.
• Coaching and developing Team Leaders to strengthen leadership across the organization.
• Streamlining and improving claims processing workflows to enhance efficiency and scalability.
• Partnering with other claims operations teams to optimize backend processes, systems, and policies.

In this role, you will play a critical part in ensuring the success and scalability of our claims operations, contributing directly to the efficiency and quality of our claims processes in a dynamic and fast-growing environment.

What you’ll do: 

• Lead and support the execution of day-to-day operations for our medical plans, ensuring operational rigor, performance management, and team development. Key responsibilities include:
• Team Leadership & Performance Management: Manage a team of 3–5 Team Leaders, providing coaching, feedback, and professional development to ensure high performance and effective team management. Implement performance management processes to track and improve individual and team outcomes.
• Identify and Mitigate Risks: Proactively identify risks in existing processes and develop strategies to mitigate those risks, ensuring continuous improvement in operations.
• Enhance Reporting & Operational Rigor: Develop and refine reporting capabilities to provide actionable insights, maintain operational rigor, and track key performance indicators (KPIs) across teams. Ensure adherence to operational standards and drive consistency across all processes.
• Subject Matter Expertise in Claims Operations: Serve as a health plan policy operations expert with a deep understanding of claims processing, including medical claims adjudication, coding procedures, regulatory requirements, and compliance standards. Utilize this expertise to guide the team in resolving complex claims issues, optimizing claims workflows, and ensuring alignment with industry best practices. Leverage knowledge of claims submission, editing, and adjustment processes to scale operations effectively and improve team performance.
• Cross-Functional Collaboration: Partner with Legal, Member Advocacy, Member Claims, Client Success, and Client Issue Resolution teams to resolve escalated issues and contribute to delivering an exceptional member experience.
• Drive Scalability & Process Improvement: Lead quarterly team projects and cross-functional initiatives focused on improving process scalability, enhancing workflows, and driving operational improvements. Apply a scalability lens to optimize resources and capabilities.
• Policy Development & Compliance: Develop and maintain policies and procedures for CX teams, ensuring they align with industry standards and compliance requirements. Continuously evaluate current operations, identify opportunities for improvement, and implement best practices to maintain operational rigor.
• Internal Leadership: Act as a key member of the internal Benefits Council, contributing to the development of Collective Health policies and plan coverage through the review of complex cases.
• Stay Informed: Monitor industry trends, regulatory changes, and current events to ensure the team remains informed and adapts to evolving policies and procedures.
• This role will position you as a leader in driving operational success and fostering cross-functional collaborat