Claims Operations Manager (Hybrid in Helena, MT)

Summary

The Claims Operations Manager is responsible for overseeing and managing the daily operations of the claims department. This role requires candidates to reside locally in the Helena, MT area to accommodate our hybrid work model. This role is pivotal in managing healthcare claims processing operations, including overseeing the receipt, adjudication, calculation, payment, and reporting of claims submitted by providers. The position ensures all activities are completed in compliance with contractual requirements, relevant laws and regulations, and established claims policies and procedures.

In addition to managing day-to-day claims operations, this role involves contributing to and developing business and operational strategies for Claims Adjudication. The goal is to enhance efficiency, optimize profitability, and maintain high levels of client satisfaction, all while supporting our broader CX and Centers of Excellence objectives.

We are looking for individuals with strong critical thinking and analytical skills, as the position requires the ability to analyze claims data and recommend strategies to increase auto-adjudication rates and streamline processing. Monitoring and driving productivity within the unit will also be a key responsibility.

Regular interaction with the customer is another important aspect of this position, including serving as the escalation point for complex client concerns and resolving them in a professional manner. The MT Claims Manager will also play a significant coaching and leadership role, evaluating staff performance, setting priorities and goals, and coordinating training needs to ensure the team’s ongoing development.

Your role in our mission

• Supervise and coordinate the daily operations of the claims department, ensuring timely and accurate claims processing.
• Establish and monitor performance metrics, service level agreements (SLAs), and department goals.
• Coach, mentor, and develop claims staff, including performance evaluations and training initiatives.
• Review and resolve complex or escalated claims issues, ensuring compliance with company policies and regulatory standards.
• Implement process improvements to enhance efficiency, accuracy, and customer satisfaction.
• Oversee the use of claims management systems and ensure data integrity and confidentiality.
• Collaborate with underwriting, customer service, legal, and finance teams to address interdepartmental issues and support business objectives.
• Prepare and present regular reports on claims operations, trends, and key performance indicators (KPIs) to senior management.
• Maintain up-to-date knowledge of industry regulations, trends, and best practices.
• Handle customer complaints and inquiries with professionalism, ensuring prompt resolution and positive outcomes.

What we're looking for

• Bachelor's degree in business administration, insurance or related field
• Five (5) or more years of healthcare (Medicaid/Medicare) claims processing or insurance operations experience
• Two (2) or more years of management or supervisory experience in a claims processing or insurance operations environment
• Proficient in claims management software and Microsoft Office Suite.
• Strong knowledge of healthcare insurance claims processes, and regulatory requirements.

What you should expect in this role

• Hybrid in Helena, MT
• This is a full-time permanent regular salaried (W-2) employee position.
• Monday through Friday work schedule (may require extended hours during peak periods or to address urgent issues).
• Health (medical, dental, vision) benefits start on day 1 of employment.
• Company match 401K and other benefits available within months of starting.
• New employees are eligible to take advantage of flexible vacation policy after ninety (90) calendar days of employment. Any exception requires manager approval prior to employee's Gainwell start date.
• Company provided computer for work use.

• For all hybrid and remote positions employees' Broadband Internet connections, should have a minimum speed of 24MBS download and 8 MBS upload.  Greater speeds will of course provide better performance.

• Video cameras must be used during all interviews, as well as during the initial week of orientation if hired. The use of AI during interviews is prohibited.
• This position will remain posted to take applications until May 1, 2026.

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