Manager Health Claims Processor

We are excited to welcome a talented and experienced professional to join the USGI as Manager – Health Claims. In this role, you will be responsible for leading the end-to-end health claims processing function, ensuring timely, accurate, and compliant claim adjudication while maintaining high standards of customer service. You will oversee daily claims operations, ensure adherence to TPA governance protocols, insurer requirements, and audit standards, and drive process efficiency across the claims lifecycle.

The role will play a critical part in managing TPA operations, including oversight of TPA-processed claims, ensuring adherence to agreed service levels, governance frameworks, and performance metrics. You will be responsible for driving TPA governance, conducting reviews of claims processes, and ensuring compliance with insurer requirements, contractual obligations, and regulatory guidelines.

• Oversee daily health claims processing operations, ensuring timely and accurate adjudication.
• Implement and enforce TPA governance guidelines and insurer audit protocols for all claims.
• Develop and execute cost-effective strategies to enhance claim processing efficiency and profitability.
• Analyze claim processing data, identify trends, and implement process improvements for cost reduction.
• Collaborate with cross-functional teams to resolve complex claim issues and ensure regulatory compliance.
• Stay updated on industry trends, implement innovative solutions, and ensure data privacy and security.
• Prepare and present regular reports to senior management, providing insights and recommendations.
• Manage stakeholder relationships with insurers, TPAs, and business partners.
• Ensure compliance with all applicable regulatory and compliance requirements.

• Bachelor's degree in healthcare administration, business, or a related field.
• Minimum 5 years of experience in health claims processing, with leadership experience.
• In-depth knowledge of TPA governance, insurer audit processes, and cost management strategies.
• Strong analytical skills for data interpretation and process improvement.
• Excellent communication and interpersonal skills for effective team collaboration.
• Proficiency in claim processing software and MS Office applications.
• Ability to work independently, manage multiple tasks, and make sound decisions.
• Problem-solving skills and a proactive approach to resolving complex claims.
• Flexibility to adapt to changing industry regulations and requirements.
• A passion for continuous improvement and a commitment to delivering exceptional services.