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Lead the CMAS team delivering claims audit, appeals, recoveries, and quality oversight. Ensure accuracy, compliance, inventory management, and timely turnaround. Manage claim inventory against SLAs; set priorities for staff. Coach and develop staff; ensure alignment with benefit plans; monitor performance. Develop and refine operational and quality KPIs; focus on day-to-day performance and regulatory compliance. Identify process improvements including automation and AI-enabled enhancements to boost efficiency and turnaround. Bachelor’s degree or equivalent work experience required. 5+ years in healthcare claims administration; self-funded/TPA preferred. Experience leading teams in claims audit, appeals, recoveries, quality, or escalations. Strong understanding of benefit administration, claims adjudication, and regulatory requirements. Experience with automated/integrated claims adjudication systems (e.g., Javelina, Health Rules Payer). Proficiency with Word, Excel, Outlook, and PowerPoint.
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