Claims Operations Manager-Payment Accuracy

📋 Description

• • Conduct deep, end-to-end investigations into complex operational issues, identifying root causes across people, process, policy, and technology within claims processing.
• • Work through designated operational queues with high attention to detail, ensuring well-supported and clearly documented determinations for payment accuracy.
• • Translate individual errors or anomalies into broader themes, trends, and systemic improvement opportunities to prevent recurrence.
• • Partner cross-functionally with Operations, Product, Engineering, Compliance, and Finance teams to implement durable, scalable solutions.
• • Create clear documentation, decision frameworks, and feedback loops to institutionalize fixes and improve operational consistency.
• • Use data to validate hypotheses, quantify the impact of process changes, and measure improvement over time.
• • Explore and implement AI-driven solutions, including AI agents and LLM-supported workflows, to enhance investigation quality and automate repetitive analytical tasks.
• • Serve as a trusted advisor and escalation point for ambiguous, high-impact operational issues requiring expert judgment.
• • Operate independently in fast-paced, ambiguous environments with sound judgment and a focus on systemic improvement.
• • Influence without direct authority by building alignment across departments to drive operational excellence and payment accuracy.
• • Maintain rigorous standards for documentation, analysis, and communication to ensure transparency and accountability in claims operations.
• • Contribute to shaping how AI and automation tools are integrated into the claims department to scale efficiency and reduce human error.
• • Identify process gaps and drive measurable operational improvements that directly impact payment accuracy and member experience.
• • Communicate complex findings and recommendations clearly and effectively through written and verbal channels to diverse stakeholders.
• • Stay current with emerging operational technologies and AI tools to continuously improve investigation methodologies and workflow design.