Operations Claims Processing Manager

About the role

The Operations Claims Processing Manager leads all Medicaid Claims Processing operations and serves as the primary point of contact for claim-related operational functions. This role oversees Claims Resolution, Drug Rebate activities, Medical Policy, Financial Transactions, and Data Entry operations.

Responsibilities

• Serve as the primary point of contact for all Medicaid Claims Processing operations.
• Manage and oversee Claims Resolution, Drug Rebate operations, Medical Policy, Financial Transactions, and Data Entry functions.
• Define, implement, and maintain operational policies and procedures.
• Identify opportunities for operational improvement and drive process enhancement initiatives.
• Lead, coach, and develop claims processing teams and operational staff.
• Ensure adherence to established operational processes, policies, and compliance requirements.
• Maintain operational tools and systems to support efficient claims processing.
• Own and drive achievement of operational Service Level Agreements (SLAs) and Key Performance Indicators (KPIs).
• Analyze operational performance metrics and produce reports for leadership and stakeholders.
• Serve as the primary point of contact regarding CMS regulations, Medicaid policies, and State Plan requirements.
• Partner with internal and external stakeholders to ensure accurate and timely claims processing.
• Manage escalated operational issues and implement corrective actions as needed.

Requirements

• Bachelor's degree in Computer Science, Information Systems, Healthcare Administration, Business Administration, or a related field; or equivalent combination of education and experience.
• Minimum of eight (8) years of experience managing Medicaid claims processing operations or major healthcare payer claims operations.
• Demonstrated experience leading claims processing teams and complex operational functions.
• Strong knowledge of Medicaid claims processing, reimbursement methodologies, and healthcare operations.
• Experience managing operational metrics, SLA performance, and KPI reporting.
• Excellent written, verbal, and presentation communication skills.
• Strong analytical, organizational, and problem-solving abilities.
• Ability to thrive in a fast-paced, high-volume, and high-pressure environment.
• Must complete a background check that includes fingerprinting.