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Collective Health · 1 day ago

Manager of Specialty Claims Processing

Lehi, UT

Full-time

Hybrid

Mid, Senior Level

$96K/yr - $120K/yr

5+ years exp

Collective Health is transforming how employers and their people engage with their health benefits by integrating technology and compassionate service. The Manager of the Specialty Claims team is responsible for overseeing claims and clinical review activities related to specialty claims management, ensuring compliance, and driving process improvements.

Health CareHealth InsuranceInsurTech

Responsibilities

Lead, manage, and develop a high-performing claims operations team, including direct oversight of a team leader

Foster a collaborative, accountable, and performance-driven culture

Provide ongoing coaching, training, and development to team members and leadership

Set performance goals, conduct regular performance reviews, and build succession plans for future complex claims management talent

Ensure timely and accurate adjudication of COB claims in alignment with regulatory standards, payer rules, and CMS guidelines

Oversee the intake, management, and resolution of CMS demand letters to ensure compliance, minimize financial exposure, and meet strict deadlines

Monitor daily workload, address bottlenecks, and ensure quality and productivity standards are consistently met

Leverage COB expertise to troubleshoot complex cases and provide escalated support

Serve as a Subject Matter Expert on Medicare/ CMS and commercial order of benefits as well as the complexities around End Stage Renal Disease (ESRD) and dialysis treatment and billing practices

Maintain expert knowledge of federal regulations, especially Medicare Secondary Payer (MSP) rules including demonstrated knowledge of coordination periods for primacy determinations

Implement quality assurance controls to ensure claims are processed accurately and consistently

Partner with QA and Compliance teams to support routine audits, perform root-cause analyses, and respond to compliance checks that maintain operational integrity

Ensure the team adheres to CMS, regulatory, and internal compliance requirements

Partner closely with internal departments such as Member Services, Claims Operations, Eligibility, Product, Legal, Network, Client Success, Workforce Optimization, and Analytics

Build and maintain strong relationships with medical network partners to drive process enhancements and operational improvements

Collaborate with leadership across the MCA organization to align on best practices, shared goals, and process optimization

Generate and analyze operational reports to track productivity, quality, turnaround time, CMS demand letter compliance, and team performance

Identify trends, operational risks, and opportunities for efficiency enhancements

Present insights to senior leadership and recommend actionable strategies to strengthen operational outcomes

Evaluate and redesign workflows to improve speed, accuracy, and scalability

Lead or contribute to department-wide projects and initiatives with minimal oversight

Enhance external and internal communication pathways for escalations, documentation, and operational coordination

Mentor the Supervisor and emerging leaders to strengthen leadership competencies and operational judgment

Provide guidance on team management, escalation handling, quality improvement, and staff development

Qualification

Claims ManagementCoordination of BenefitsMedicare Secondary PayerLeadershipAnalytical SkillsHealth Insurance ExperienceTeam DevelopmentProcess ImprovementMedical TerminologyCPT/HCPCS CodingICD-10 Coding

Required

2+ years of supervisory or people-leadership experience within an operations environment

Minimum of 5 years of experience in a health insurance, managed care, or claims environment

Demonstrated capability in leading through ambiguity, successfully navigating change, and maintaining team performance and focus during periods of operational transition or uncertainty

To be comfortable learning and mastering the technical aspects of COB adjudication

A proven track record of scaling teams, driving change, and improving operational processes

A passion for developing high-performing teams and supporting early-career professionals

Strong analytical skills with the ability to interpret data and guide performance improvements

Proven ability to influence without authority, drive consensus across functional teams, and secure commitment for operational improvements

Minimum of 2 years of supervisory or management experience leading a team of claims or benefits professionals

Strong Coordination of Benefits expertise or prior experience directly supporting COB operations

In-depth, demonstrated expertise in Coordination of Benefits (COB), the Medicare Secondary Payer (MSP) statute, and its application to End-Stage Renal Disease (ESRD) and dialysis

Proven understanding of industry practices related to provider claims submission and billing, especially regarding dialysis and high dollar claims submissions

Solid understanding of medical terminology, CPT/HCPCS coding, and ICD-10 codes, particularly those related to chronic kidney disease and dialysis