Claims Manager – Maryland Medicaid

CVS Health • Edgewater, FL

11d

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary The Manager of Claims Management is responsible for overseeing Medicaid claims operations, inventory management, quality assurance, and compliance monitoring. This role ensures timely and accurate processing of Medicaid claims in accordance with state and federal regulations, contractual requirements, and organizational performance standards. The manager partners cross-functionally with Provider Relations, Configuration, Compliance, Finance, Appeals and Grievance. and Medical Management.

Requirements

• Bachelor’s degree in Business, Healthcare Administration, or related field (or equivalent experience).
• 3–5+ years of progressive claims experience in Medicaid.
• Strong understanding of Medicaid billing rules, HSCRC, provider types, benefit structures, and encounter reporting.
• Experience with major claims systems (e.g., QNXT).
• Problem solving mindset; adaptable, ability to analyze processes.
• Proven ability to drive performance and optimize operational workflows.
• Analytical skills with proficiency in Excel and claims data analysis.
• Job responsibilities are not limited to the description above.

Nice To Haves

• Experience with Medicaid managed care organizations (MCOs) or state Medicaid agencies.
• Knowledge of fee schedules, and Medicaid pricing methodologies.
• Background in payment integrity, claims audits, configuration testing, or encounter operations.
• Lean Six Sigma or process improvement certification.

Responsibilities

• Manage daily Maryland Medicaid claims operations to ensure timely and accurate claims adjudication and payment.
• Direct and support claims supervisors, auditors, and analysts; provide coaching, workload direction, and performance management.
• Oversee inventory levels, turnaround times (TAT), backlog reduction, reduction of claims interest, suspended claims work queues (not sure of what this is), and provider dispute resolution.
• Drive improvements in auto-adjudication rates, accuracy, and first-pass resolution.
• Ensure all claims processes comply with: State Medicaid regulations and billing guidelines CMS requirements and Federal managed care rules Timely filing laws and encounter data reporting requirements Support readiness reviews, audits, Corrective Action Plans (CAPs), and state submissions.
• Implement QA programs to monitor claim accuracy, provider payment integrity, and policy adherence.
• Review and analyze claims performance dashboards, error trends, and key metrics (TAT, payment accuracy, denial rates, encounters, etc.).
• Partner with Finance on claims reserves, cost-of-care reporting, and reconciliation issues.
• Work closely with Configuration, Cotiviti and Claim Xten to resolve system issues, benefit configuration errors, and pricing or editing defects.
• Partner with Provider Relations to address contractual interpretation questions and recurring provider submission issues.
• Collaborate with Utilization Management/Medical Management on authorization-related claims issues.
• Coordinate with Compliance and Legal on regulatory changes and required process updates.
• Lead initiatives to streamline workflows, automate processes, reduce manual interventions, and improve accuracy.
• Drive root-cause analysis and implement sustainable corrective actions.
• Participate in the development of policy and procedure updates for Medicaid claims operations.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 5,001-10,000 employees