Claims Administrator

TITLE: CLAIMS ADMINISTRATOR/ ASST. MANAGER

REPORTS TO: Claims Manager

FLSA STATUS:

HIPAA: Compliance Level

SUMMARY

The Claims Administrator plays a vital role in supporting the training and development of the Claims staff. This position is focused on creating and delivering effective training programs for Claims personnel, clients, and service providers, working closely with the Claims Manager to enhance team performance, ensure compliance with policies and regulations, and drive operational efficiency. The role includes assistant management duties, daily operational support, and contributions to process improvements. Additionally, the Claims Administrator will develop and document standard operating procedures and Claims policies while coordinating audit responses and client requests. The role requires a proactive leader committed to learning, development, and operational excellence within the Claims Department.

ESSENTIAL FUNCTIONS

• Identify ways to improve employee efficiency and effectiveness.

Oversees, trains, and evaluates the performance of staff, providing guidance and support as needed.

• Assist in processing claims when necessary.
• Supports State Directories and/or the Director of Internal Audits with state/clients' audits.
• Manage the Telecommuter program, Claims Account Representative, and Claims Specialists II, ensuring adherence to department standards.

Provide feedback on revisions to policies and procedures and on the development of work processes.

• Identify and investigate potential fraud.
• Demonstrates the ability to interpret and apply plan-specific contract provisions.
• Assist clients with complaints regarding billing submissions.
• Assist with projects, development of reports, and perform other program-related duties as assigned.
• Represent the organization at client meetings, professional association events, and workshops.
• Develop and maintain training materials including handbooks, demonstration models, multimedia visual aids, computer tutorials, and reference workshops.
• Partner with management to develop and execute scheduled specialized training sessions focused on system enhancements, workflow changes, new products or product changes, as well as policy/procedure changes.
• Conduct training needs analysis to determine specific training needs for department staff and evaluate effectiveness of the training.
• Audit work and coordinate training initiatives to identify, develop, and publish corrective actions and educational materials.
• Perform other duties as assigned.

QUALIFICATIONS REQUIRED

Minimum of 3 years of leadership experience

Minimum of 5 years of claims processing experience preferred

Minimum of 3 years of training experience preferred, with a focus on developing training programs and materials.

Must adhere to HIPAA standards.

Proficiency in using standard office equipment, including copiers, fax machines, phones, and computer hardware/software

Demonstrates strong proficiency in Microsoft Excel

Excellent written and verbal communication skills, capable of engaging effectively with executive management and staff.

Ability to formulate and modify policies, train, and direct staff in best practices

Strong customer service focus and the ability to engage with a diverse group of internal and external customers

Exceptional organizational skills, ability to focus on assigned tasks.

Able to work collaboratively, diplomatically, and with integrity in problem identification and problem-solving activities.

MINIMUM REQUIRED EDUCATION/TRAINING

Bachelor's Degree in Business or related fields

Must be able to travel occasionally

Must have three years of training experience.

Must have three to five years of experience formulating training curricula.

Must have three to five years of experience using multimedia visual aids.