Medicare Claims Processing Leader, Medicare Claims #921

Over 35 years strong and fueled by 1,700 smart, passionate employees across New York state and Vermont, MVP is full of opportunities to grow.  We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds—tech people, numbers people, even people people—working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference—it’s time to make a healthy career move to MVP!

Status: Full-time, Exempt

Provide technical and administrative oversight to a team of cross-functional Medicare, DSNP and UVMNH claim examiners for adjudication of claims and adjustments. Responsibilities will include ensuring that all activity is consistent with company policies and procedures. The role will also provide oversight and direction in the duties of monitoring attendance, personnel issues, and performance evaluations, interviewing and completing the disciplinary action process, as needed. Will also support and mentor to successfully build highly skilled team members. Achieves operational objectives by contributing information and recommendations to strategic plans and reviews; preparing and completing action plans; implementing automation, production, and quality standards; resolving problems; identifying trends; determining system improvements; implementing change. Effectively handle, root cause, and resolve internal and external customer complaints. Provide guidance and direction to team members and external departments.

Responsible for staff scheduling, including PTO time, back-up for employees and cross-training for extended absences. This role will be responsible for representing department during audits by federal, state and client entities.  Responsible for understanding the Medicare and DSNP model contracts, and all applicable federal and state regulations and mandates related to Medicare Advantage and Essential Plan services and products.  Works with other departments to establish and maintain collaborative relationships toward achieving company goals. Act as back up to Leader of Gov’t Programs and Integrated Health. Attend meetings as needed. Handle escalated issues effectively or escalates to their Leader items outside their immediate control. Ability to maintain confidentiality and adhere to regulatory compliance issues as they exist and change from time to time. Performs other related duties as assigned. 




Minimum Education: 

4 year college degree, preferrable in Business Administration or Business Management, or three or more years of related work experience.


Minimum Experience: 

Minimum three years claim processing required. One year of supervisory experience in claims or call center preferred. 


Required Skills: 

·        Familiar with ICD-10, CPT, HCPCS and Revenue codes 

·        Strong commitment to customer service and understanding and responding to customer needs within specific timeframes 

·        Strong problem-solving skills and demonstrated ability to follow through on issues to resolution

·        Strong understanding of Policies and Procedures and able to create and maintain new processes.

·        Strong verbal and written communication skills 

·        Ability to manage multiple assignments with a high level of autonomy and independence.

·        Familiar with Word, Excel, Dynamics & Microsoft Office.

·        Experience with FACETS preferred

About MVP
MVP Health Care is a nationally recognized, not-for-profit health insurer caring for more than 700,000 members in New York and Vermont. Committed to the complete well-being of our members and the communities we serve, MVP makes health insurance more convenient, more supportive, and more personal.  We are powered by the ideas and energy of more than 1,700 diverse, employees from all backgrounds, committed to having a positive impact on the health and wellness of everyone we serve. MVP Health Care is an Affirmative Action/ Equal Employment Opportunity (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), and the EEO is the Law Poster and Supplement protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at

Please apply and learn more – including how you may become a proud member of our team.

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