Senior Manager, Claims Operations

Senior Manager, Claims Operations

We are seeking an experienced Senior Manager, Claims Operations to lead and strengthen our claims function and help build the processes, controls, reporting, and technology infrastructure necessary to support our continued growth.

Position Summary

The Senior Manager, Claims Operations will have primary responsibility for overseeing MediDrive 's end-to-end claims operations, including claims submission, adjudication, reconciliation, encounter reporting, remittance processing, provider payment support, and claims-related financial reporting.This individual will work closely with Operations, Finance, Accounting, Product, Technology, and our healthcare clients to ensure claims are processed accurately, reconciled completely, and reported appropriately.

A critical component of this position will be the ability to understand and manage 835 remittance files, 837 claims/encounter transactions, Medicaid encounter reporting, Medical Loss Ratio (MLR) reporting, and transportation-related claims and provider payments .

This is a hands-on leadership role. The successful candidate will not only manage existing claims processes but will also identify gaps, develop solutions, establish controls and KPIs, and help create a scalable claims operating model as MediDrive continues to grow.

Key Responsibilities

Claims Operations & Management

- Lead the day-to-day operation of the claims function and oversee the complete claims lifecycle from initial submission through adjudication, payment, denial, adjustment, and final reconciliation.

- Develop and maintain scalable claims workflows, policies, procedures, and internal controls.

- Monitor claims volumes, payment activity, outstanding claims, denials, rejections, adjustments, and exceptions.

- Identify duplicate, rejected, incorrectly processed, or unresolved claims and drive issues through resolution.

- Establish claims aging and exception-management processes to ensure outstanding items are identified and resolved timely.

- Ensure claims operations comply with applicable contractual, client, Medicaid, and regulatory requirements.

835 / 837 & Encounter Management

- Oversee the processing, validation, and reconciliation of 835 Electronic Remittance Advice (ERA) files.

- Manage and understand 837 healthcare claims and encounter transactions , including submission, acceptance, rejection, and reconciliation.

- Oversee Medicaid encounter reporting and ensure submitted encounter data is complete, accurate, and reconciled to underlying claims and transportation activity.

- Work closely with Technology and Product teams to identify and resolve EDI, data, claims-processing, and system integration issues.

- Develop controls to ensure claims and encounter files are successfully transmitted, accepted, and appropriately reflected in downstream financial and operational systems.

Medical Loss Ratio (MLR) & Financial Reconciliation

- Partner with Finance and Accounting to support accurate and timely Medical Loss Ratio (MLR) reporting and analysis.

- Reconcile claims and transportation expenses to client funding, provider payments, remittance activity, and financial reporting.

- Assist Finance with month-end claims accruals, incurred-but-not-paid claims, outstanding provider liabilities, and other claims-related accounting requirements.

- Provide visibility into claims trends and cost drivers that may impact client profitability and MLR performance.

- Ensure appropriate reconciliation between operational claims systems and the General Ledger.

Transportation Provider Payments

- Oversee claims-related processes supporting payments to transportation providers.

- Develop controls to ensure transportation providers are paid accurately and only for properly validated and approved transportation services.

- Reconcile provider payments to underlying trip and claims data.

- Partner with Finance and Operations on provider payment processes, including paym