Director of Managed Care Operations

UMass Memorial Health•Worcester, MA

7d•$101,026 - $181,854•Onsite

About The Position

The Director, Managed Care Operations provides executive-level leadership and oversight for all managed care operational activities across the UMass Memorial Health (UMMHC) system, including UMass Memorial Medical Center, UMass Memorial Medical Group, member hospitals, and all affiliated ancillary providers. The Director serves as the primary system-wide liaison to managed care plans, ensuring seamless communication, operational alignment, and compliance with contractual requirements. This role leads the implementation of new and evolving payment models, oversees resolution of complex operational issues, and represents Managed Care Operations in senior-level committees and cross-functional initiatives. The Director is the primary liaison with managed care plans relative to communication and implementation of all applicable plan policies and procedures and resolution of operations issues arising under the system’s managed care contracts. The Director also leads quarterly operations meetings with member hospitals and plays a key role in system-wide initiatives such as utilization review, specialty pharmacy expansion, and new product or service-line implementations.

Requirements

Bachelor’s degree in Business Administration, Healthcare Management, or related field.
Experience working within both health plan and hospital system environments.
Minimum of 10 years of experience in a managed care setting, with deep knowledge of clinical operations, healthcare terminology, and managed care policy.
The document states: “Must have 10 year’s experience in Managed Care setting; thorough understanding of clinical operations, health care terminology, and managed care policy.”
Demonstrated leadership experience managing teams and complex operational functions.
Exceptional communication, negotiation, and relationship‑building skills.
Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Nice To Haves

Master’s degree in Healthcare Administration, Business, Public Health, or related discipline.

Responsibilities

Lead the design, execution, and continuous improvement of managed care operational strategies across the UMMHC system.
Direct implementation planning for new contracts, payment model transitions, and risk-based arrangements.
Serve as the authoritative resource on managed care operational requirements, ensuring alignment between payer expectations and internal workflows.
Anticipate operational impacts of regulatory, contractual, or market changes and proactively develop mitigation strategies.
Act as the primary liaison with all contracted health plans, ensuring timely communication, issue resolution, and operational compliance.
Customize operational protocols to reflect payor contractual requirements and evolving plan policies.
Lead cross-functional workgroups to operationalize new payer programs, benefit designs, and population-specific initiatives (e.g., Dual Eligible Demonstration Projects, specialty pharmacy programs).
Oversee monthly claims operations and medical management meetings, ensuring timely resolution of escalated issues.
Provide direction to internal departments on complex claims, provider enrollment barriers, and administrative or clinical appeals.
Develop and monitor performance metrics geared toward improving claims accuracy, reducing denials, and enhancing reimbursement.
Directly supervise Managed Care Operations staff, including hiring, training, performance evaluations, and professional development.
Foster a culture of accountability, collaboration, and continuous improvement.
Promote diversity, equity, and inclusion in hiring, and team development.
Evaluate operational performance, identify improvement opportunities, and implement data-driven solutions.
Partner with finance, contracting, and clinical leadership to assess the financial impact of operational changes and payer policies.
Ensure compliance with all regulatory agencies (e.g., Joint Commission, DPH) and internal policies.
Maintain and update departmental procedures to meet evolving regulatory and payor requirements.
Lead or participate in performance improvement initiatives, embedding quality improvement principles into daily operations.
Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.
Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.
Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.
Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation; and fosters the effective integration of efforts with system-wide initiatives.
Encourages and supports diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, respect, tolerance, civility and acceptance toward all employees, patients, and visitors.
Integrates diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc.
Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
Ensures compliance with regulatory agencies such as Joint Commission, DPH (Department of Public Health), etc. Develops and maintains procedures necessary to meet regulatory requirements.
Ensures that department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures.
Ensures adequate equipment and supplies for department.
Develops and maintains established departmental policies, procedures, and objectives.
Ensures compliance to all health and safety regulations and requirements.
Maintains, regular, reliable, and predictable attendance.
Performs similar or related duties as required or directed.