The Managed Care Manager leads the operational management of contract adjudication and claims processing within the managed care finance function. This role is responsible for ensuring the accurate and timely adjudication of claims according to contractual agreements, overseeing a team of analysts, and driving continuous improvements in claims workflows and compliance. The ideal candidate combines deep knowledge of managed care contracts and claims processes with strong leadership, operational management skills, and effective communication.

Key Responsibilities:

• Lead and manage the daily operations of contract adjudication and claims processing, ensuring accuracy and compliance with payer and provider agreements.
• Supervise, mentor, and develop a team of Managed Care Analysts focused on claims adjudication and contract compliance.
• Oversee the interpretation and application of managed care contract terms to guide accurate claims adjudication and resolution of contract-related disputes.
• Collaborate cross-functionally with negotiation teams, revenue cycle, and IT departments to resolve adjudication issues and implement process improvements.
• Drive enhancements to adjudication workflows and system configurations to improve accuracy, efficiency, and scalability.
• Manage multiple projects aimed at optimizing contract claims processing and operational performance, ensuring deadlines and quality standards are met.
• Serve as a primary point of contact for stakeholders regarding contract adjudication issues and operational inquiries.
• Conduct regular audits and quality checks to maintain compliance with contractual obligations and regulatory standards.
• Develop training programs to enhance team knowledge of evolving managed care contracts, claims procedures, and industry regulations.
• Maintain confidentiality and integrity of sensitive contract and claims information at all times.

Qualifications:

• Bachelor’s degree in healthcare management, public health, accounting, finance, or business degree is required.
• 7+ years of experience in managed care operations, with a focus on contract adjudication and claims management.
• Strong understanding of healthcare managed care contracts, claims processing workflows, and reimbursement methodologies.
• Proven leadership skills with experience managing and developing operational teams.
• Familiarity with contract adjudication systems and claims processing platforms.
• Exceptional critical thinking and problem-solving abilities.
• Excellent organizational and project management abilities, with a capacity to manage multiple priorities effectively.
• Strong communication skills with the ability to collaborate across departments and with external partners.
• Detail-oriented with a commitment to accuracy, compliance, and continuous process improvement.
• Advanced knowledge of Microsoft Excel to organize, analyze, and validate large data sets, including proficiency with pivot tables, LOOKUPs, and data validation techniques.
• Ability to handle sensitive information with discretion and professionalism.