Medicaid Claims Manager Priority Health


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Job Summary

Job Description

Provide leadership and direction to the Medicaid Claim Processing teams to ensure that the goals and standards of the department and Priority Health are being met. Facilitate the development of the team within the Claims department. Participate in ongoing development of new products and technologies.
DIRECTION EXERCISED: Manage the Medicaid Claims Team Leaders.

Directly supervises above mentioned employees in accordance with Priority Health’s policies and applicable Federal and State Laws. Responsibilities include but are not limited to effectively interviewing, hiring and training employees; planning, assigning and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems.

Essential Functions


  • Ensure that all team members are treated with respect and fairness
  • Facilitate the development of the Medicaid team within the Claim Services department.
  • Serve as coach, facilitator and motivator to the teams, removing operational roadblocks that result in teams not achieving the operational objectives.
  • Ensure that individual team meetings are routinely scheduled to discuss performance results, operational issues, and provide all team members the opportunity to explore alternative approaches to exceed the current performance levels.
  • Identify training requirements for individual team members and overall training needs for the entire team to further develop the performance of the teams within the Claims teams.
  • Coordinate with the Learning and Development Team all necessary refresher training and new product training required.
  • Provide opportunities for and encourage professional growth of individual team members.
  • Work with team to set goals.
  • Effectively educate team on an ongoing basis relative to day to day changes, company initiatives and communications (internal or external) that may directly effect their interpretations of policy changes or benefit clarification to members, participants, providers, employers and the Priority Health staff.

  • Develop and implement performance tracking and trending tools to allow for daily monitoring of the team’s performance level for all functions to ensure that departmental standards are met.
  • Review the performance of assigned team members on at least a quarterly basis. Identify successes and areas of improvement. Implement appropriate counseling and performance improvement action plans according to Human Resource regulations and guidelines. Termination of employment, when necessary, would be coordinated with Human Resources and Manager’s direct report.
  • Ensure consistency exists with the application of operational policies and procedures within the various teams.
  • Ensure all benefit language, policies and procedures are interpreted accurately within the teams.
  • Monitor team operational and financial performance and initiate corrective actions when required.

  • Auditing and reporting of claims.
  • Investigation and resolution of inter/intradepartmental inquiries regarding claims status, benefit issues and adjudication errors.

  • Participate in Process Improvement Planning (PIP)
  • Effectively develop, prioritize and implement project plans as assigned by management.
  • Communicate project progress in a clear and timely manner.

  • Represent department in various meetings and committees
  • Implement activities to meet customer requirements based on internal feedback and customer survey results.

  • Monitor any delays or issues with cycle times and develop corrective action plans. Ensure trend reporting is developed and distributed to key personnel.
  • Maintain knowledge of operational functions and software.
  • Maintain general knowledge of other functional areas of the system and Priority Health business to better assess the impacts of the Operational functions.
  • Facilitate continuing improvement of business processes in Claims.
  • Provide technical analysis and recommendations as requested by management or staff regarding a variety of issues or problems.
  • Identify ways to re-engineer the operational procedures to gain efficiency in operational processes.
  • Exercise fiscal responsibility in managing team budgets.
  • Participate in ongoing development of new products and technologies. Ensure that Claim Services can administer new and existing products effectively and efficiently.
  • Assist in handling members with potential grievances in an effort to achieve an acceptable outcome.
  • Create, develop, and design any forms or spreadsheets needed within the department to use for collecting and/or reporting data.
  • Other duties as deemed appropriate by Sr. Manager of Claims and/or Chief Operating Officer (COO) of Enterprise Operations.
  • Represent department in audit related activities at group, state and/or federal levels to ensure compliance requirements are maintained.



  • Required Bachelor’s Degree


  • 3 years of experience typically gained through skills/knowledge/abilities managed care experience and/or training; or equivalent combination of education and experience Required
  • 3 years of experience typically gained through skills/knowledge/abilities management experience in a managed care or health care environment Required
  • Excellent working knowledge of managed care concepts and HMO operations Required
  • Government programs operational experience Preferred
  • Knowledge or experience related to TQM, Process Improvement or Reengineering Methodologies


Primary Location

SITE – Priority Health – 1239 E Beltline – Grand Rapids

Department Name

PH – Claims Administration

Employment Type

Full time


Day (United States of America)

Weekly Scheduled Hours


Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

Variable weekends

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health’s application process. Contact us at 616-486-SHHR (7447).

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

category. See more here .


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