Claims Specialist

BrightonOne • Boston, MA

15d • $70,000 - $90,000 • Hybrid

About The Position

The Senior Specialist, Vendor Performance Management supports day-to-day oversight and accountability of USFHP vendors, with subject-matter depth in claims. The role manages assigned vendor relationships and performance, partners with technical subject-matter experts to define and operationalize service-level agreements and accountability plans, and serves as a claims-process subject-matter expert. The position analyzes performance, drives remediation, and helps ensure vendors deliver accurate, timely, and compliant service.

The position is full-time and hybrid, with four days per week in the Brighton, Massachusetts office and one day remote. It is classified as exempt. The employee must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment, and must be authorized to work in the United States without sponsorship now or in the future.

Requirements

• Bachelor's degree preferred, or equivalent experience.
• At least 4 years of vendor management, claims operations, or health plan operations experience.
• Strong knowledge of claims processing, adjudication, and vendor/SLA management.
• Analytical and problem-solving skills, with the ability to drive vendor accountability.
• Excellent communication and collaboration skills with technical subject-matter experts and vendors.
• Proficiency in Microsoft Office Suite and platforms such as Facets, QNXT, HealthRules, or similar systems.
• Familiarity with CMS, URAC, NCQA, TRICARE, and healthcare regulatory requirements.
• Familiarity with CAQH, NPPES, PECOS, and provider credentialing databases.
• High attention to detail and commitment to data accuracy, including the ability to analyze complex data and identify discrepancies for regulatory compliance.
• Exceptional organizational and time-management skills, with the ability to manage multiple priorities in a fast-paced environment.
• Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.
• Must be authorized to work in the United States without sponsorship now or in the future.

Nice To Haves

• Claims operations subject-matter expertise.
• Experience with Medicare, TRICARE, managed care, or government-sponsored health programs.

Responsibilities

• Manage assigned vendor relationships and monitor performance against SLAs and scorecards; conduct regular operational reviews.
• Partner with technical subject-matter experts to define, develop, and operationalize vendor accountability plans, requirements, and corrective actions.
• Track issues and remediation through resolution and support delegation and performance audits with evidence.
• Serve as a subject-matter expert on claims processing, adjudication logic, edits, and vendor claims performance.
• Analyze claims accuracy, timeliness, and financial data to identify issues, root causes, and improvement opportunities.
• Support claims configuration validation, testing, and issue triage with vendors and internal teams.
• Prepare vendor performance reporting and documentation consistent with TRICARE/USFHP, DHA, and accreditation requirements.
• Maintain audit-ready records and support governance reporting.
• Partner with operations, compliance, finance, and clinical teams on vendor issues and process improvements.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior