The Manager Claims Business Rules Configuration leads the strategy, design, and execution of claim system configuration to support accurate, efficient, and compliant claims processing.

This role oversees daily operations, optimizes configuration rules, drives process improvement, and ensures the successful delivery of configuration initiatives across all products and programs. 

KEY RESPONSIBILITIES

Operational Leadership 

• Oversee daily operations and performance of the Claims Systems Configuration team. 

• Develop, track, and report on departmental KPIs. 

• Ensure accurate and optimized claims processing through strong data integrity and continuous process improvement. 

• Provide approval for configuration deployments, documentation, and training materials. 

• Maintain departmental audit controls and partner with Compliance to ensure readiness for internal or external audits. 

Configuration Strategy and Execution 

• Lead the design and implementation of claim business rule configurations, including clinical and admin policy, benefit, provider, and authorization rules. 

• Manage change control, risk assessments, issue resolution, and progress reporting. 

• Support the refinement activities of configuration requests and design align with approved requirements. 

• Recommend system improvements to increase auto-adjudication rates and streamline claims processing. 

Documentation, Training and Quality 

• Oversee development and maintenance of departmental work instructions, policies, and workflows. 

• Ensure effective training materials are created and maintained for configuration processes. 

• Conduct and oversee audits to ensure adherence to processes and documentation standards. 

Team Leadership and Development 

• Motivate and guide the team to meet performance expectations and departmental goals. 

• Support Supervisors and Trainers in developing staff knowledge and capabilities. 

• Assist with personnel management activities, including hiring, performance evaluations, and disciplinary actions. 

• Provide escalation support for complex configuration or client issues. 

Cross-Functional Collaboration 

• Partner with governance and process improvement teams to refine workflows and remove impediments. 

• Collaborate with internal teams to provide education on system configuration and support corrective action responses. 

• Ensure knowledge transfer across departments and support broader organizational initiatives. 

Minimum Education, Licensure and Professional Certification

• High school diploma required

• Bachelor’s degree in healthcare or computer related field preferred

Minimum Experience Required 

• 5+ years’ experience of business rule configuration in a claims adjudication platform, to include clinical and admin policy rules, provider contract rates and benefit management. 

• 7+ years’ experience in healthcare claims life cycle 

• 2+ years of supervisor experience 

Skills 

• Proficiency in Excel, Word and Access, required. Advanced in Excel, preferred 

• Knowledge of SQL Data Query, Power BI, preferred 

• Proficiency in Claim Business Rule configuration in a claims adjudication platform, required 

• Knowledge healthcare IT claim adjudication systems, claims processing, healthcare data sets (ICD-10, CPT/HCPC, etc.) 

• Knowledge of Agile, Kanban, Jira board and dashboard management 

• Strong analytical and critical thinking skills, required 

• Strong decision-making skills, required 

• Strong aptitude for process improvement, required 

• Strong communication skills, required 

• Ability to supervise, multitask and work independently in a fast-paced environment are essential skills for this position