Claims Operations Manager

Mass General Brigham•Somerville, MA

58d•Hybrid

About The Position

Claims Operations Manager, Health Plan The Manager, Claims Operations is a critical role within the Claims Operations areas. We are hiring for two open manager roles; Medicaid and Commercial lines of business. Each role will oversee a large department of seasoned professionals with a wide array of skills. The ideal candidate will possess excellent communication and organizational ability. They will have a strong aptitude for technology and its impact on claims operations. The Claims Operations Manager is responsible for managing claims operations to ensure efficient and accurate processing of claims. Oversees claims workflows, compliance, and team performance to support revenue cycle goals and optimize reimbursement processes. Responsible for planning, directing, and coordinating the day-to-day operations of the Claims Operations teams (including the claims reviewer team and the resolution team), ensuring that all metrics are achieved for quality, time, inventory, and aging for original claims and provider correspondence.

Requirements

Bachelor's Degree Healthcare Administration required, or bachelor's degree Business Administration required, or bachelor's degree in a related field of study required
Can this role consider and review experience in lieu of a degree? Yes
Experience in claims management or revenue cycle operations 5-7 years required
Experience in a supervisory or leadership role 2-3 years required
Thorough knowledge of claims processes, insurance requirements, and healthcare regulations.
Strong leadership and team management abilities.
Proficiency in claims processing systems and revenue cycle management tools.
Excellent analytical skills to assess and improve claims performance metrics.
Effective communication and interpersonal skills for collaboration and issue resolution.
Ability to manage multiple priorities in a fast-paced and dynamic healthcare environment.
Attention to detail and a commitment to maintaining compliance and accuracy.

Nice To Haves

Certified Professional Coding - Preferred
Experience in automation implementation and leveraging AI technology to streamline business processes.

Responsibilities

Monitors accurate reporting of claim key metrics including but not limited to claim turnaround times, denial rates, quality scores, claims over 30 and 45 days, customer service statistics, call tracking and correspondence inventories and turnaround, data entry numbers, and turnaround time.
Set clear goals and objectives and use metrics to measure performance and hold staff accountable.
Provide coaching to improve performance and hold regular development.
Leads the claims operations team, including hiring, training, and performance management.
Oversees the processing and submission of claims to ensure accuracy, timeliness, and compliance with payer requirements.
Monitors claim metrics to identify trends, reduce denials, and improve revenue cycle performance.
Implements and updates policies and procedures to align with regulatory standards and organizational goals.
Collaborates with billing, coding, and clinical teams to address claims issues and resolve discrepancies.
Manages relationships with insurance payers to streamline claims adjudication and reimbursement processes.
Prepares and presents performance reports and improvement strategies to hospital leadership.