CLAIMS OPERATIONS MANAGER SKILLS, EXPERIENCE, AND JOB REQUIREMENTS

The Claims Operations Manager brings a robust background in managing Call/Contact Centers and collaborating with outsourced service providers, combined with expertise in call center metrics to enhance operational efficiencies. With a strong foundation in Managed Care, this role capitalizes on extensive knowledge of reimbursement methodologies, Claims Auditing Software, and regulatory compliance with CMS and TDI guidelines. Proficiency in communication, alongside a deep understanding of enrollment, eligibility, and utilization review processes, ensures effective management and oversight within healthcare operations.

Essential Hard and Soft Skills for a Standout Claims Operations Manager Resume
  • Claims Processing
  • Regulatory Compliance
  • Data Analysis
  • Risk Management
  • Insurance Law Knowledge
  • Financial Reporting
  • Policy Review
  • Process Improvement
  • Software Proficiency
  • Quality Control
  • Leadership
  • Communication
  • Problem Solving
  • Decision Making
  • Attention to Detail
  • Negotiation
  • Adaptability
  • Team Management
  • Strategic Thinking
  • Empathy

Summary of Claims Operations Manager Knowledge and Qualifications on Resume

1. BA in Business Administration with 4 years of Experience

  • Knowledge of property claims contracts and interpretation of case law
  • Knowledge of Xactimate, Xactanalysis and Xact Contents
  • Experience handling moderate to complex dwelling and liability claims
  • Experience managing Examiner Level claims professionals (complex property)
  • Experience with P&C claims leadership and development skills
  • Superb interpersonal skills including verbal and written communications
  • Strong training, coaching, and mentoring skills
  • The ability to work under pressure, meet deadlines and manage expectations in a fast-moving environment.
  • Strong commercial awareness.
  • Experience in working and implementing change in matrix organization.
  • Proven leadership skills and the ability to coach and motivate others.
  • The ability to plan and organize, making the best use of time and resources.

2. BA in Finance with 3 years of Experience

  • Experience in managing Call/Contact Centres, as well as working with outsourced service providers.
  • Experience in call center metrics with the ability to analyze performance and drive through efficiencies.
  • Excellent communication skills, written and verbal.
  • Experience in a Managed Care environment as a Supervisor, Sr. Claims Analyst, or Claims Coordinator.
  • Extensive knowledge of reimbursement methodologies specific to Facility and Professional Claims.
  • Extensive knowledge of Claims Auditing Software
  • Knowledge of DRG Payment, Grouper/Pricers
  • Experience with delegation Oversight  (Health Plan, CMS)
  • Excellent communication skills
  • Knowledge of enrollment, eligibility, and utilization review processes.
  • Knowledge of industry standards
  • Specific to CMS and TDI.

3. BA in Risk Management and Insurance with 5 years of Experience

  • Experience in developing business strategy and executing on transformational changes whilst ensuring that existing business priorities continue to be delivered.
  • Ability to influence and collaborate effectively with senior managers and multiple stakeholder groups across the organization to develop and execute change road maps.
  • Experience assessing technology solutions and implementing changes / new solutions working in partnership with vendors and internal IT.
  • Experience in developing quality monitoring controls that use data to assess claims quality that can be applied down to the business unit and individual claims handler in a scalable way
  • Strong analytical skills and comfortable with the use of data to drive business outcomes.
  • Experience in delivering a multi-line claims QA program
  • Understanding of processes and best practices that provide a robust control framework
  • Experience in using/reporting from different audit tools and implementing process improvements.
  • Experience in developing best practices that can be applied by claims teams globally using the CAPDAN approach.
  • Understand the improvement opportunities identified and be credible with key claims stakeholders & managers.
  • A track record of driving continuous business improvement.
  • Strong people management skills with an ability to engage and lead a team.
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