Claims Operations Manager
Plymouth Meeting, PA US
Posted 1 day ago
Job Description
Claims Operations Manager (122118)

Looking for a meaningful job where the work you do truly makes a difference in people's lives every day?

West's Health Advocate Solutions division is currently seeking a Claims Service Operations Manager to join our fast paced team in Plymouth Meeting, PA. The core focus of this position will be managing several teams in our claims department, which includes monitoring case loads, monitoring service metrics, as well as staff development.

We offer Great Benefits!
The benefits package for this position includes very generous Paid Time Off (PTO), paid holiday policy, tuition reimbursement and a 401(k) with a match. Health Advocate has an Employee Assistance Program, wellness programs, and employee activities to support employees with various goals.

Our Claims Service Operations Manager is responsible for:

  • Managing the service operations units case load
  • Attainment of service metrics and staff development ensuring development and implementation of hiring initiatives to meet the growth targets
  • Provide business support to internal departments to determine if appropriate steps have been completed on specific cases
  • Monitor performance guarantees to minimize financial impacts ensuring to escalate any issues to management
  • Partner with internal departments (e.g., Training, Quality, etc.) to develop and implement performance improvement strategies

Employee and Personal Leadership Development:

  • Coach, develop, and mentor subordinates to achieve quality performance while continuing to develop personal management skill necessary to lead staff and handle unique management challenges
  • Promote employee development by establishing performance measures that encourage employees to excel
  • Participate in the development of strategies to find optimal solutions to compensate, attract, and retain the talent necessary to achieve established goals and objectives
  • Assist staff with establishing and attaining career development goals
  • Ensure that employee training is effectively conducted for all positions throughout assigned area of responsibility
  • Conduct appraisals and performance reviews
  • For staff located within the United States, ensure compliance with Equal Employment Opportunity/Affirmative Action (EEO/AA) guidelines
  • Comply with individual country employment laws and regulations based on location of staff
  • Review and recommend suggestions to management when updates to job descriptions are required as responsibilities change
Team Interface/ Customer Service:
  • Establish and maintain a professional relationship with internal/external customers, team members and department contacts
  • Cooperate with team members to meet goals or complete tasks
  • Provide quality customer service that exceeds customer expectations and improves level of service being provided
  • Treat all internal/external customers, team members and department contacts with dignity/respect
  • Escalate to supervisor any situation outside the employee's control that could adversely impact the services being provided



  • Bachelor's degree from an accredited college or university with major course work in business administration, liberal arts, public health, healthcare management, or a related field required
  • Equivalent work experience in a similar position may be substituted for educational requirements


  • Minimum of 3 years of healthcare, health plan or benefits experience required preferably in a call center environment
  • Minimum one year lead or supervisor experience required
  • Minimum 2 years of health benefits or health insurance appeals experience required
  • Minimum 2 years of claims or claims processing experience required


  • Intermediate knowledge of Word and Excel is required
  • Ability to search and identify resources through company Intranet and Internet

Knowledge of the following is preferred:

  • Group Health Plans (fully insured and self-insured)
  • Summary Plan Documents (SPDs) and Certificates of Coverage (COCs)
  • Government programs, resources, legislation and mandates; examples include Affordable Care Act, Medicare, Medicaid, COBRA
  • High deductible health plans including Health Reimbursement Accounts (HRAs) and Health Saving Accounts (HSAs)
  • Coordination of benefits and which plan is primary - simple and complex cases (commercial plans, Medicare plans)
  • Reviewing, interpreting, and researching Explanation of Benefits (EOB's) and denial letter
  • Understanding of health plan authorizations, including medical policy and claims payment guidelines to evaluate if appeals require clinical or administrative review
  • Understanding of insurance carrier claims processing and knowledge of procedure and diagnosis coding (ICD, HCPCS, and CPT)
  • Knowledge of applicable law and resources regarding confidentiality of privileged patient information and appeals administration

We are connecting people and ideas.

We are delivering on their potential.

We are improving the way we work and live.

West is the leading independent provider of healthcare advocacy products and services to employees of large organizations. Our Health Advocate division serves 40 million Americans through more than 10,000 client relationships, including many of the nation's largest companies. By helping members personally maneuver healthcare and insurance-related issues, we save our customers time and money. Our leading-edge technology platform combined with clinical experts can support consumers with any healthcare or health insurance issue. West leverages the power of data analytics with pricing transparency and personalized health communications to help members make better-informed decisions and get more value from the healthcare system. Additional services include wellness coaching, Employee Assistance Programs (EAP), nurse line, biometrics screenings and chronic care solutions.

We connect. We deliver. We are West.

Applications accepted 07/24/18.

Equal Opportunity Employer/Veterans/Disabled

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EEO/AAP Employer-Minorities/Women/Disabled/Protected Veterans


Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Bachelor's Degree
Required Experience
3+ years
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