Manager Claims - LHB (Tribal Health)

📋 Description

• • Lead and inspire a high-performing team of Claim Analysts and outsourced vendor partners who process medical claims for Tribal health plans, ensuring every member receives accurate, timely, and culturally sensitive service.
• • Own the daily operations of one or more Claims Units, driving quality, production, and service metrics that directly impact member satisfaction and client retention for Luminare Health’s fastest-growing book of business.
• • Translate complex Tribal healthcare rules—Payor of Last Resort, MLR requirements, Sponsorship, Chef reimbursement, COB, and Self-Funded plan nuances—into clear procedures that your team can execute flawlessly while maintaining strict compliance.
• • Act as the escalation point for intricate claim scenarios and high-visibility client issues, leveraging your deep technical knowledge to resolve disputes, prevent rework, and protect the member experience.
• • Partner with Client Managers, Implementation teams, and external vendors to onboard new Tribal clients, translating benefit designs, SPDs, and contractual terms into actionable workflows and system configurations.
• • Champion continuous process improvement by analyzing claim data, identifying root-cause trends, and launching initiatives that reduce cycle time, increase auto-adjudication rates, and lower cost per claim.
• • Develop and retain top talent through targeted coaching, performance dashboards, and curated learning paths that align with HCSC’s award-winning career development philosophy.
• • Manage vendor SLAs, conduct monthly business reviews, and negotiate corrective action plans to ensure outsourced partners deliver the same quality standards as internal teams.
• • Present monthly operational scorecards to senior leadership, highlighting wins, risks, and strategic recommendations that influence product design, technology roadmaps, and client pricing strategies.
• • Foster a remote-first culture of accountability and inclusion, using virtual huddles, recognition programs, and cross-training to keep geographically dispersed teams engaged and cohesive.
• • Ensure adherence to HIPAA, CMS, and Tribal regulatory requirements by maintaining airtight documentation, audit trails, and security protocols across all claim platforms.
• • Leverage advanced Excel, proprietary claim systems, and emerging RPA tools to automate repetitive tasks, freeing analysts to focus on complex, value-added work.
• • Serve as the voice of the customer inside the organization, translating member feedback and Tribal council priorities into actionable enhancements that strengthen long-term partnerships.