Quality Claims Manager (National Remote)

About the role

The Manager, Claims Quality leads the day-to-day work of the Claims Quality team and is accountable for quality planning, quality assurance, quality control and continuous improvement across Medical, Dental and Pharmacy Claims. The role provides people leadership, directs claims-quality audits and calibrations, monitors quality and operational performance, strengthens governance and controls, coordinates issue remediation and turns findings into clear actions for operational and senior leaders. It is a full-time, Monday to Friday position, national remote, with 6 weeks of virtual on-the-job training.

Key responsibilities

• Lead and manage the Claims Quality team, set priorities, allocate workload, coach employees and ensure operational coverage.
• Oversee quality audits, sampling, findings, trends and follow-up across Medical, Dental and Pharmacy Claims.
• Lead internal and external audit calibration and quality-governance activities, keeping audit methodology and scoring consistent.
• Analyze audit findings, defects and operational data to identify risks, recurring issues and improvement opportunities.
• Lead quality issue management and corrective action, including root-cause analysis, remediation planning and effectiveness monitoring.
• Strengthen operational and quality controls and oversee quality reporting and governance.
• Drive continuous-improvement initiatives to improve claims accuracy and reduce defects and rework.
• Work cross-functionally with Claims Operations, Clinical Quality, Compliance, Program Integrity, Analytics, Training and external partners.
• Maintain quality documentation and knowledge management, and carry out special ad-hoc audits and reviews.

Required profile

• High school diploma / GED or equivalent work experience; 18 years of age or older.
• 3+ years of healthcare claims experience (Medical, Dental, Pharmacy or comparable).
• 2+ years of people-leadership experience, including direct-report management, SME or formal team-lead responsibility.
• 2+ years of quality assurance, claims auditing, compliance monitoring or operational quality experience.
• 2+ years leading or supporting claims audits, calibration, error trending or remediation.
• 1+ year working across Operations, Quality, Compliance, Analytics, Clinical or other cross-functional stakeholders.

Required skills

• Intermediate Microsoft Excel (filtering, sorting, pivot tables, charts, structured data analysis).
• Proficiency with Microsoft Word, PowerPoint, Teams and SharePoint.
• Preferred: quality dashboards, control matrices, risk registers, ServiceNow, Smartsheet, process mapping, Lean Six Sigma or similar certification.