Senior Operations Manager

Job Summary:

The primary role of the Payment Integrity Operations Sr Manager is to lead a team of analysts in support of client strategies for identifying errant claim payments. Responsible for managing analysts in areas of auditing, ideation, and data analysis and programming. Types of overpayment reviews will include, but are not limited to Duplicate Payment, Contract Compliance, Authorizations, Eligibility, Coordination of Benefits, Medical Review, DRG Review, and Medicare and Medicaid reimbursement policies.

Why You'll Love Working at ClarisHealth

We believe our team deserves the best, and we’re proud to offer a comprehensive benefits package designed to support your success, both at work and in life. Here’s what you can look forward to:

• Medical, Dental, and Vision Insurance – Enjoy medical, dental, and vision insurance that begins on your first day, ensuring your health and wellness are always supported.
• 401(k) with Matching and Immediate Vesting – Secure your financial future with a company match and instant vesting.
• Company-Paid Short-Term Disability (STD) – Added security for unforeseen circumstances.
• Company-Paid Personal Financial Advising – Expert guidance to help manage your finances.
• New Hire Stipend – A one-time stipend to purchase home office supplies (laptop and charging cable provided by the company).
• Pet Insurance Options – Choose from two carrier options to keep your furry friends covered.
• Paid Holidays – 9 company holidays plus 2 floating holidays for added flexibility.
• Virtual Counseling and Telemedicine – Company-paid access to mental health and medical support from the comfort of your home.
• Paid Parental Leave – Time to focus on family during this special chapter.
• Generous Vacation & Wellness Time – 4 weeks of vacation beginning accrual on day one, plus 1 additional week for wellness.
• Professional Development Stipend – After one year, enjoy a $500 annual stipend to invest in professional growth (e.g., certifications, webinars).

You may be ideal if you have:

• 5+ years of experience in management
• Experience meeting quarterly and annual identification and revenue targets
• Client-facing experience
• Deep understanding of standard coding and reference materials used in a claim setting, such as CPT4, ICD10, HCPCS, and others
• 2 + years coding/auditing claims for Medicare and Medicaid plans
• Expert Excel skills and intermediate SQL highly preferred
• Strong analytical and critical thinking skills required Expert knowledge of industry reimbursement standards, payer/provider contracting, and claims processing protocols
• Expert knowledge of DRG, CPT, and Revenue codes and how claims should be reimbursed
• Effectively demonstrated the ability to drive projects to completion
• The ability to collaborate with external teams and effectively communicate the message

Responsibilities:

• Work with team members to ensure project goals are met in an efficient and effective manner
• Maintain required levels of production and quality standards as established by management
• Creates and maintains files in accordance with management policies and guidelines by obtaining and attaching all appropriate documentation to clearly identify an audit trail for the audit performed Communicate to SLT & ELT any issue(s) that would impede the accurate and timely review of claims
• Work with Client Experience Managers and Account Executives to ensure that these issues are resolved
• Drive effective dialogue with Senior Leaders regarding query effectiveness, concept velocity, and revenue reporting
• Acquire knowledge of the client’s claims adjudication system, provider contracts, and client claim payment policies and procedures
• Resolve or escalate issues that may affect the review of claims
• Will work with Accounts Receivable staff to research and/or answer questions from providers regarding overpayments
• Responsible for coaching and training on the review of healthcare claims and investigates to determine Medicare/Commercial primacy by recognizing and investigating known indicators and communicating with healthcare providers, employers, members, and/or Medicare representatives to gather information to support the primacy determination
• Responsible for building and maintaining strong client relationships requiring daily/weekly interaction with customer points of contact and executives

Other Duties:

This job description in no way states or implies that these are the only duties to be performed by this employee. This position will be required to follow any other instructions and to perform any other duties requested by his/her supervisor. Individuals will always be expected to maintain a professional work environment.

About ClarisHealth

ClarisHealth, based in Nashville, Tenn., provides health plans and payers with a better way to drive claims payment accuracy. Its proprietary, A.I.-powered enterprise technology platform Pareo® allows health plans across the U.S. to reduce manual work, gain insights into operational performance across lines of business, and accelerate their strategy to overpayment prevention – at a significantly reduced cost.

Company Culture

Our company values help everyone move in alignment toward this mission. We are …

Compassionate. We practice servant leadership, encourage inclusion and engagement, and actively acknowledge and celebrate each other’s contributions.

Communicators. We listen first with an emphasis on understanding. We seek solutions to problems, and practice radical candor with positive intent.

Challengers. We get the right stuff done right, create clarity from complexity, take accountability and ownership, and we challenge ourselves daily.

ClarisHealth embraces a supportive working culture of creativity and innovation internally termed “Got Your Back.” We live out this #GYB spirit every day by working together with team members, clients, and other partners to achieve shared goals.

For more information about ClarisHealth and our culture, please visit us at https://www.clarishealth.com/careers/.

Other

Applicants must be currently authorized to work in the United States on a full-time basis. ClarisHealth is not able to sponsor applicants for work visas.

EOE, including Disability/Veterans; anyone needing accommodation to complete the interview process should notify the People Operations team.