Claims Adjudication Manager

Claims Adjudication Manager

Location: Makati, Valero

Reports to: VP - Operations 

Position Summary:

We are looking for an experienced Claims Adjudication Manager to lead and optimize the end-to-end medical claims adjudication function for US health plan operations. This is a high-impact, client-facing leadership role that requires strong operational expertise, exceptional communication skills, and the ability to drive performance in a fast-paced environment.

Work Arrangement

This position will initially be in-office and will transition to a remote set-up upon successfully meeting performance goals and KPIs. Please note that this is a performance-based role, and the company reserves the right to require employees to report onsite at any time based on:

• Business needs
• Performance evaluations
• Operational requirements

Key Responsibilities:

Operational Leadership

• Manage daily adjudication operations ensuring accuracy, productivity, and SLA attainment.
• Monitor team performance through dashboards, scorecards, and KPIs.
• Lead huddles, coaching sessions, and handle escalations.
• Implement early warning systems to prevent SLA risks.
• Drive continuous improvement to reduce errors and delays.

Training & Development

• Design and implement structured training programs, curriculum, and learning modules.
• Develop assessments, certifications, and progression criteria.
• Conduct refreshers, new-hire training, and remediation programs.
• Track and report training progress to leadership and clients.

Quality Assurance

• Develop and maintain QA guidelines and audit processes.
• Oversee QA reviews, scoring, and error trend analysis.
• Implement calibration sessions and manage rebuttal processes.
• Provide QA reports and root-cause analysis to clients.

Client Engagement

• Act as the primary operational point-of-contact for client communications.
• Respond promptly to inquiries and escalations.
• Deliver weekly and monthly business reviews covering performance, quality, training, and SLA compliance.

Compliance & Process Management

• Ensure adherence to regulatory standards and contract requirements.
• Maintain updated SOPs and enforce workflow compliance.
• Collaborate with HR, WFM, QA, Training, and Client Services teams.

Key Competencies

• Operational Excellence – Drives KPIs, SLAs, and quality outcomes.
• Training & Development – Builds robust training ecosystems.
• Quality Management – Expertise in audits and error analysis.
• Client Communication – Professional, timely, and solutions-oriented.
• Leadership – Inspires and coaches high-performing teams.
• Strategic Thinking – Anticipates risks and drives improvements.

Qualifications:

• 5+ years of experience in US healthcare claims adjudication with end-to-end process knowledge.
• 2–3 years of leadership experience managing adjudication teams (100–150 FTEs) or QA/training functions.
• Strong understanding of medical terminology, coding (ICD, CPT, HCPCS), plan structures, and benefit rules.
• Excellent verbal and written communication skills; highly responsive to clients.
• Proven ability to create training programs and certification paths.
• Experience managing KPIs and SLAs in a BPO or healthcare operations environment.
• Strong analytical and problem-solving skills; data-driven decision-making.
• Ability to thrive in a fast-paced environment and manage multiple priorities.
• Experience supporting US health plans or TPAs.
• Exposure to AI-assisted adjudication tools or digital transformation initiatives.
• Background in quality assurance or instructional design.

Requirements:

• Amenable to work nightshift/ US Hours, holidays and weekends.
  
• Willing to report onsite -Makati as required by business needs.
• Can start ASAP

What we Offer

• Comprehensive HMO Coverage (Medical/Dental)
  • Coverage on Day1 + 1 Free Dependent
• Competitive Salary
  

Step into a client-facing leadership position where your skills matter. Apply now and fast-track your career!