Claims Manager

Benefits

• Paid Holidays
• Health Reimbursement Account
• Pensions
• Health insurance
• Paid time off

Summary

The Claims Manager is responsible for supervising, coordinating, and implementing a wide range of departmental projects and programs, as well as overseeing the day-to-day operations of the Claims Department. The Claims Department processes medical, dental, vision, disability, and HRA claims and provides customer service support to participants.

Essential Duties and Responsibilities

• Process and audit all types of claims—including medical, dental, vision, HRA, and loss-of-time (short-term disability)—for active members and retirees.
• Ensure claims are processed accurately and meet quality, timeliness, and production standards.
• Research and resolve appealed, questionable, or denied claims to ensure fair and timely outcomes.
• Conduct phone monitoring to ensure quality service.
• Respond promptly and professionally to phone, written, and walk-in inquiries from participants, trustees, employers, and union representatives.
• Draft written correspondence regarding claim inquiries, determinations, and appeals.
• Coordinate programming updates and client communications for Plan changes.
• Run reports as needed. Analyze report data and notify Administrative Manager of concerns or recommendations for improvement.
• Collaborate with consultants, attorneys, and management on benefit interpretations, subrogation, workers’ compensation, and preparation of plan materials and booklets.
• Communicate and collaborate with vendors such as PBM, PPO, UR, Case Management, etc as needed.
• Support efforts to improve electronic claims productivity and auto-adjudication rates.