Manager, Claims Operations

What you will do:

• Manage and develop a team of Claims and Appeals Processors, providing training, feedback, and performance management to ensure SLA and quality targets are consistently met
• Own end-to-end claims operations, including adjudication, appeals, QA, IDR negotiations, and compliance with plan policies and regulatory requirements
• Develop and strengthen scalable processes by documenting SOPs, identifying workflow improvements, and leading automation or tooling initiatives that reduce friction and improve accuracy
• Manage customer support and provider escalations, partnering closely with CX, Network Operations, Sales, and Broker teams to resolve issues efficiently and represent Claims Operations with professionalism and clarity
• Oversee rule-based payment logic, collaborating with Product and Engineering to maintain and enhance our claims rules engine and operational systems (Jira, internal platforms, reporting tools, etc.)
• Build and maintain plan document infrastructure ensuring operational accuracy,alignment with claims logic and network rules, and regulatory compliance
• Serve as claims subject-matter expert for internal teams, manage vendor relationships, and ensure timely support for Stop Loss reporting and required documentation.
• Develop KPIs and reporting dashboards to monitor performance, uncover trends, and drive continuous operational improvement
• Partner on payment integrity and cost containment programs, leveraging data and vendor partnerships to reduce waste, ensure appropriate reimbursement, and protect plan assets
• Drive cross-functional projects, coordinating requirements, timelines, and stakeholders for system changes, rule updates, plan documents, and process improvements

About you:

• 4+ years of experience in health insurance claims processing, with strong familiarity across institutional and professional claims, coding standards (ICD, CPT/HCPCS, revenue codes), and regulatory requirements
• 2+ years managing and developing teams in fast-paced, metrics-driven environments, with a track record of building high-performing, accountable teams
• Exceptionally organized with strong time-management skills, able to prioritize competing deadlines, manage escalations, and keep multiple workflows moving in parallel
• Process-builder with a startup mindset and who is comfortable creating structure from ambiguity, documenting SOPs, and improving systems while adapting quickly to change
• Gritty problem-solver who’s willing to dive into the details, ask foundational questions, and work through complex or ambiguous scenarios to get to clarity
• Excellent verbal and written communication skills, with the ability to synthesize data from disparate sources, tell a clear story, and communicate effectively to both technical and non-technical audiences
• Analytical and data-driven, with experience in spreadsheets and (ideally) SQL to support operational reporting, trend analysis, and KPI development
• Stop Loss and Independent Dispute Resolution (IDR) experience is a plus, but not required.

Benefits:

• Remote company with a fully distributed team – no return-to-office mandates
• Flexible vacation policy (and a culture of using it)
• Medical, dental, and vision insurance with 100% company-paid employee coverage
• 401k w/ company match
• FSA, and HSA plans
• Paid parental leave
• Short and long-term disability, as well as life insurance
• Competitive stock options are offered to all employees
• Transparent compensation & formal career development programs
• Paid one-month sabbatical after 5 years
• Stipends for setting up your home office and an ongoing learning budget
• Direct positive impact on members’ lives – wait until you see the positive feedback members share every day