Project Manager - Healthcare Claims Management

The Project Manager – Healthcare Claims Management (Subject Matter Expert) is responsible for leading complex projects and initiatives related to claims adjudication, processing, compliance, and operational improvements. This role requires deep subject matter expertise in healthcare claims systems, workflows, and regulatory requirements. The PM will collaborate with cross-functional teams to ensure timely, accurate, and compliant claims operations while driving strategic enhancements.

SALARY: $95,000.00/Annually

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

The PM’s responsibilities include but are not limited to:

Lead and manage end-to-end projects focused on healthcare DME claims.

Serve as the subject matter expert for claims workflows, system configurations, and industry best practices.

Oversee requirements gathering, business analysis, and documentation of claims processes.

Ensure claims-related projects meet compliance with HIPAA, CMS, Medicaid, and other applicable regulations.

Partner with IT, operations, and vendor teams to resolve system defects, improve processing accuracy, and optimize turnaround times.

Manage stakeholder communications, project status reporting, and escalation of risks or issues.

Facilitate user acceptance testing (UAT) for claims-related enhancements and system changes.

Monitor and track project performance, ensuring deliverables are met within scope, budget, and schedule.EDUCATION: Bachelor’s degree in healthcare administration, business, or related field, or equivalent experience required.

EXPERIENCE:

5+ years of experience in healthcare claims management, with at least 3 years in a project management capacity.

Deep knowledge of claims adjudication systems (e.g., QNXT, Facets, HealthEdge) and HIPAA EDI transactions (837, 835, 277, 820).

Proven experience leading cross-functional projects in a payer or managed care environment.

Strong understanding of CMS, Medicaid, and state-specific claims regulations.

Excellent communication, organizational, and analytical skills.