The Manager of the Specialty Claims team is responsible for the overall operational management and oversight of all claims and clinical review activities related to specialty claims management, including but not limited to End-Stage Renal Disease (ESRD)/dialysis services and Coordination of Benefits (COB) for complex medical cases. This role ensures regulatory compliance, maximizes cost savings through accurate payment determination, and drives process improvements to maintain high-quality member service. The Manager will lead a team of claims examiners serving as the company’s subject matter expert in the intersection of commercial/ self funding health insurance, Medicare Secondary Payer (MSP) rules (specifically the 30-month coordination period), and federal and state regulations governing dialysis coverage.

What you'll do:

• Leadership & People Management
  • Lead, manage, and develop a high-performing claims operations team, including direct oversight of a team leader.
  • Foster a collaborative, accountable, and performance-driven culture.
  • Provide ongoing coaching, training, and development to team members and leadership.
  • Set performance goals, conduct regular performance reviews, and build succession plans for future complex claims management talent.
• Specialty Claims Management Oversight
  • Ensure timely and accurate adjudication of COB claims in alignment with regulatory standards, payer rules, and CMS guidelines.
  • Oversee the intake, management, and resolution of CMS demand letters to ensure compliance, minimize financial exposure, and meet strict deadlines.
  • Monitor daily workload, address bottlenecks, and ensure quality and productivity standards are consistently met.
  • Leverage COB expertise to troubleshoot complex cases and provide escalated support.
  • Serve as a Subject Matter Expert on Medicare/ CMS and commercial order of benefits as well as the complexities around End Stage Renal Disease (ESRD) and dialysis treatment and billing practices
  • Maintain expert knowledge of federal regulations, especially Medicare Secondary Payer (MSP) rules including demonstrated knowledge of coordination periods for primacy determinations.
• Quality Assurance & Compliance
  • Implement quality assurance controls to ensure claims are processed accurately and consistently.
  • Partner with QA and Compliance teams to support routine audits, perform root-cause analyses, and respond to compliance checks that maintain operational integrity.
  • Ensure the team adheres to CMS, regulatory, and internal compliance requirements.
• Cross-Functional Collaboration
  • Partner closely with internal departments such as Member Services, Claims Operations, Eligibility, Product, Legal, Network, Client Success, Workforce Optimization, and Analytics.
  • Build and maintain strong relationships with medical network partners to drive process enhancements and operational improvements.
  • Collaborate with leadership across the MCA organization to align on best practices, shared goals, and process optimization.
• Performance Analysis & Reporting
  • Generate and analyze operational reports to track productivity, quality, turnaround time, CMS demand letter compliance, and team performance.
  • Identify trends, operational risks, and opportunities for efficiency enhancements.
  • Present insights to senior leadership and recommend actionable strategies to strengthen operational outcomes.
• Continuous Improvement
  • Evaluate and redesign workflows to improve speed, accuracy, and scalability.
  • Lead or contribute to department-wide projects and initiatives with minimal oversight.
  • Enhance external and internal communication pathways for escalations, documentation, and operational coordination.
• Support & Development of Team Leads / Supervisor
  • Mentor the Supervisor and emerging leaders to strengthen leadership competencies and
    operational judgment.
  • Provide guidance on team management, escalation handling, quality improvement, and staff development.

To be successful in this role, you'll need:

• Bachelor’s degree or equivalent operational management experience (preferred).
• 2+ years of supervisory or people-leadership experience within an operations environment (required).
• Minimum of 5 years of experience in a health insurance, managed care, or claims environment.
• Demonstrated capability in leading through ambiguity, successfully navigating change, and maintaining team performance and focus during periods of operational transition or uncertainty.
• To be comfortable learning and mastering the technical aspects of COB adjudication.
• A proven track record of scaling teams, driving change, and improving operational processes.
• A passion for developing high-performing teams and supporting early-career professionals.
• Strong analytical skills with the ability to interpret data and guide performance improvements.
• Proven ability to influence without authority, drive consensus across functional teams, and secure commitment for operational improvements.
• Minimum of 2 years of supervisory or management experience leading a team of claims or benefits professionals.
• Strong Coordination of Benefits expertise or prior experience directly supporting COB operations (required).
• In-depth, demonstrated expertise in Coordination of Benefits (COB), the Medicare Secondary Payer (MSP) statute, and its application to End-Stage Renal Disease (ESRD) and dialysis.
• Proven understanding of industry practices related to provider claims submission and billing, especially regarding dialysis and high dollar claims submissions.
• Solid understanding of medical terminology, CPT/HCPCS coding, and ICD-10 codes, particularly those related to chronic kidney disease and dialysis.
• Experience overseeing COB adjudication and/or CMS demand letter processes (preferred).

Pay Transparency Statement

This is a hybrid position based out of our Lehi office, with the expectation of being in office at least two weekdays per week. #LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for 70,000 stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.