Commercial Claims Operations Manager

Mass General Brigham•Somerville, MA

2d•Hybrid

About The Position

The Claims Operations Manager is responsible for managing commercial 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. The ideal candidate will possess excellent communication and organizational ability. They will have a strong aptitude for technology and its impact on claims operations. Responsible for planning, managing, 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 required; experience can be substituted in lieu of degree
At least 5-7 years of experience in claims management required at a health plan or TPA
Experience in a supervisory or leadership role 2-3 years required
Hands-on expertise with claims adjudication, adjustments, reprocessing, and denial/appeal/RFR workflows
Strong understanding of claim coding structures: CPT/HCPCS, ICD-10, revenue codes, modifiers, MUE/CCI edits
Experience applying Commercial payer policies in claim decisioning
Regulatory & Compliance Working knowledge of: MassHealth Subchapter 6 rules CMS billing and appeal regulations State/federal turnaround time requirements Provider dispute/RFR obligations HIPAA and documentation integrity standards
Operational Leadership Management of production teams with measurable throughput, quality, and accuracy goals. Experience running daily work distribution, aging oversight, inventory governance, and backlog reduction plans. Proven ability to drive corrective action and performance improvement.
Systems & Technical Skills Claims platform experience required (e.g., QNXT, Facets, QicLink, Amisys, HealthEdge, etc.). Ability to interpret benefit configuration impacts in adjudication outcomes. Familiarity with provider file enrollment impacts, COB, pricing logic, and encounter requirements. Experience designing, implementing, and overseeing automation solutions.

Nice To Haves

Certified Professional Coding (CPC) license
Medicaid managed care experience.
Experience leading multi-line-of-business teams.
Exposure to pricing methodologies such as DRG/APR-DRG/EAPG.
Experience participating in regulatory audits or corrective action plans.

Responsibilities

Lead daily operations for claims review and resolution teams managing Commercial and/or Medicaid inventories, ensuring SLA, TAT, and accuracy compliance.
Oversee claims review and adjustments, high-dollar reviews, overpayment identification, correspondence, and research workflows.
Apply expert knowledge of payer-side adjudication rules, including MassHealth billing requirements, CMS regulations, and plan benefit configuration impacts.
Partner with Configuration, Benefits, Policy, Clinical, Provider Enrollment, Finance, and SIU to resolve systemic issues and drive root-cause elimination.
Ensure correct application of pricing methodologies (DRG, APR-DRG, fee schedules, EAPG, contract term payment logic).
Manage regulatory compliance, including MassHealth and CMS notification standards, appeal/RFR timelines, documentation requirements, and audit readiness.
Develop performance dashboards, monitor productivity and accuracy, and execute action plans for improvement.
Lead, coach, and develop a team of Review Specialists, Resolution Coordinators, Documentation Specialists; set expectations, execute feedback loops, and manage performance.
Identify workflow breakdowns, implement process improvements, and optimize throughput across multiple workstreams.
Contribute to cross-functional governance meetings and operational reporting.