Claims Manager

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Imperial Management Administrators Services

Directly responsible for oversight of day-to-day operations of a full-fledged Claims Department, including claims evaluation, adjudication, auditing, performance management, staffing, training, personnel development and the identification and implementation of quality improvement initiatives. The claims manager is also responsible for leading the claims team in the successful completion of daily tasks, and charged with ensuring that all tasks meet the requirements mandated by existing policies and procedures, requirements mandated by contracted health plans, state health care agencies, and the Centers for Medicare and Medicaid Services (CMS)



Drafts and maintains documentation, including policies & procedures, workflows, and training materials pertaining to claims operations and encounter data collection and submission.

Ensures that claims payment system data and processes are properly maintained and up to date, such as fee schedules or provider billing information.

Reports and tracks claims daily inventory and productivity, and compiles monthly or annual reports as requested by the leadership team.

Prepares, produces, and maintains reports related to claims payment timeliness, inventory, production, high-dollar claims, claims errors/suspense, claims denial(s), departmental performance and other documents, as needed.

Handles oversight of pending/pended claims and monitors claims payment compliance and standards.

Responsible for handling claims Provider disputes and other cases involving refunds, and system errors; handles corrective efforts including root-cause analyses, corrective action plans and works to ensure any errors or issues are corrected accordingly.

Develops and oversees ongoing claims audit program dedicated to ensuring that the organization is paying claims correctly and in a timely fashion, and in conjunction with correct amount with supporting authorization(s), if applicable.

Responsible for internal and external claims audits conducted by compliance department, health plans and any regulatory agencies; drafts, executes and monitors corrective action plans to address any deficiencies or risks identified by regulators or internal auditors.

Monitors and ensures EDI/electronic claims are loaded and processed in a timely manner and in accordance with established policies and pertinent regulations.

Monitors the collection/volume of encounter data and collaborates with other departments to further improve turnaround time and accuracy for encounter data processing and submission


·        High school graduate or equivalent.

·        Bachelor’s degree preferred

·        Minimum 5 years of IPA/Health Plan/Hospital claims experience

·        Experience with EZ-CAP software

·        Experience with Crystal Reports, Virtual Examiner, Symkey preferred

·        Ability to correctly adjudicate claims using the appropriate pricing tools, fee schedules, etc.


·        Knowledge of EDI and Electronic Claims Processing

·        Advanced understanding of contract terms, benefits, DOFRs & compliance guidelines.

·        Knowledge of Medicare & Medi-Cal managed care and health plan standards

·        Knowledge of provider/institutional billing practices

·        Experience with claims payment, adjudication, auditing and analyses

Knowledge of CPT/HCPCS/ICD coding

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