Manager, Claims Operations

We are hiring an experienced Claims Operations Manager to lead and scale the teams responsible for member appeals, provider reconsiderations, claims research, and adjustment processing. This leader will ensure accurate, timely, and compliant handling of post-adjudication claim activities while driving operational excellence, process integrity, and member and provider satisfaction.

The ideal candidate has deep experience in health plan operations, with a strong understanding of claim adjudication workflows, regulatory requirements (ERISA, state DOI, CMS), and cross-functional collaboration with product, engineering, legal, and client success teams. This leader will be passionate about simplifying complex processes, mentoring operational teams, and fostering a culture of accuracy, accountability, and continuous improvement.

What you'll do:

Leadership

• Build, develop, and lead a high-performing team responsible for appeals, reconsiderations, and claims adjustments.
• Foster an inclusive, engaged, and accountable team culture that emphasizes quality, timeliness, and service excellence.
• Partner cross-functionally with Customer Experience, Legal, Product, Engineering, and Client Success teams to align operational outcomes with business priorities.
• Develop and mentor team leads and individual contributors to build strong leadership and technical expertise within the team.
• Establish measurable performance goals, ensuring clear ownership and continuous improvement across all post-adjudication processes.

Operations Management

• Oversee the end-to-end operations of member appeals, provider reconsiderations, and claims adjustments, ensuring compliance with internal policies, ERISA timelines, and client expectations.
• Drive operational excellence through process standardization, clear documentation, and data-driven performance management.
• Collaborate with claims processing and configuration teams to identify and resolve root causes of adjustment trends and prevent recurrence.
• Ensure timely and accurate completion of claim research tasks, member and provider inquiries, and appeal resolutions.
• Partner with internal stakeholders to monitor service level performance, ensure adherence to turnaround times, and deliver transparent reporting on quality and productivity.

Scaling and Process Improvement

• Identify opportunities to streamline post-adjudication workflows, reduce manual effort, and enhance automation and system enablement.
• Partner with Product and Engineering to design and prioritize technology solutions that improve efficiency, accuracy, and scalability.
• Develop and implement quality assurance and audit programs for appeal and reconsideration determinations to ensure compliance and consistency.
• Use data analytics to identify process bottlenecks, volume trends, and improvement opportunities across appeal and adjustment operations.

Continuous Improvement

• Conduct end-to-end process reviews to identify gaps, inefficiencies, or compliance risks within claims research and appeals workflows.
• Develop and present business cases for process improvement initiatives, articulating the people, process, and technology impacts.
• Create and track operational metrics (quality, timeliness, accuracy, productivity) to drive a culture of performance excellence.
• Collaborate with training and quality teams to ensure consistent understanding and execution of appeal and reconsideration protocols.
  
  

To be successful in this role, you'll need:

• 5+ years of experience within Health Care operations, including management experience
• Experience leading operations and service teams, preferably in high-growth technology companies
• Health insurance experience/health plan administration experience required
• Experience implementing complex processes and projects
• Experience working cross-functionally with Legal, Engineering, Product and Customer-facing teams
• Experience working with various stakeholders including clients
• Ability to make progress, recommendations and decisions despite ambiguity
• Ability to understand, analyze and envision the end-to-end process
• Member and client focused (customer centricity)
• To enjoy a fast paced team environment and adapt well to change by adjusting priorities as needed
• To have excellent verbal, written and interpersonal communication skills
• To be analytically minded and like to make data-driven decisions
• To are a self-motivator and self-starter
• To are inspired by creating and fostering an engaged workforce

Pay Transparency Statement:

This is a hybrid position based out of one of our offices: Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office three days per week (Plano, TX) or two days per week (Lehi, UT). #LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.