Operations Claims Processing Manager

Conduent•Montgomery, AL

3d•$77,770 - $101,000•Onsite

About The Position

The Operations Claims Processing Manager is responsible for leading all Medicaid Claims Processing operations and serves as the primary point of contact for claim-related operational functions. This role provides leadership and oversight for Claims Resolution, Drug Rebate activities, Medical Policy, Financial Transactions, and Data Entry operations. The ideal candidate is an experienced Medicaid operations leader with a strong background in claims processing, regulatory compliance, performance management, and operational excellence. This individual will drive process improvements, ensure SLA and KPI achievement, and maintain compliance with CMS regulations and Medicaid State Plan requirements. This position is contingent upon the award of a government contract. Recruiting and interviewing activities may occur prior to contract award; however, employment and start dates are subject to contract award, funding, customer approval requirements, and/or satisfaction of any applicable pre-employment conditions.

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.

Nice To Haves

Experience supporting Medicaid programs or government healthcare contracts.
Knowledge of CMS regulations, Medicaid policy, and state healthcare requirements.
Experience with claims adjudication, provider reimbursement, and financial transaction operations.
Proven track record of implementing operational improvements that increase efficiency and quality.
Experience presenting operational results to executive leadership and government agency stakeholders.

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.
Monitor and manage 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.