Claims Adjudication Manager (Healthcare)

TL;DR

Claims Adjudication Manager (Healthcare): Leading a Philippines-based claims adjudication team to ensure high-quality delivery for U.S. clients with an accent on operational leadership and quality assurance. Focus on bridging client expectations with offshore execution, optimizing throughput, and establishing robust audit and documentation infrastructures.

Location: Remote (Must be U.S.-based)

Company

Leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide.

What you will do

• Provide day-to-day operational leadership for the Philippines-based adjudication team, directing priorities and removing blockers.
• Act as the senior operational single point of contact (SPOC) for the client, translating requirements into executable operating procedures.
• Own the quality program by reducing repeat errors and leading calibration sessions between examiners and auditors.
• Oversee production reporting validation and establish trusted tracking methodologies.
• Establish and maintain centralized documentation and knowledge-management processes to reduce reliance on individual knowledge.
• Collaborate with HR and recruiting to accelerate hiring and stabilize staffing levels.

Requirements

• 6+ years of U.S. healthcare claims adjudication experience with expertise in both hospital (UB-04) and professional (CMS-1500/HCFA) claims.
• 3+ years leading claims teams of 30–40+ members, ideally in an offshore or BPO/shared-services environment.
• Must be based in the United States.
• Demonstrated ability to serve as a client-facing operational leader, owning escalations and building client trust.
• Strong command of claims workflows, medical terminology, coding concepts, and payer/provider processes.
• Availability for core overlap with Philippines business hours (evening calls).

Nice to have

• Experience overseeing Philippines-based healthcare claims operations.
• Background supporting U.S. health plans, TPAs, or healthcare BPOs.
• Exposure to payment review, denials, or appeals functions.
• Experience building SOP libraries and knowledge-management processes.
• Exposure to process improvement, automation, or AI-assisted enablement tools.