Claims Operations Manager

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Nov 22, 2025
The Opportunity 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, 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. Essential Functions 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. 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 Preferred Experience Certified Professional Coding (CPC) license 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 Medicaid and/or Commercial payer policies in claim decisioning 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. Knowledge, Skills, and Abilities: 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. Working Model Requirements Hybrid role M-F Eastern Business Hours Quarterly meetings onsite as planned for business and team needs, must be flexible On remote workdays, employee must have a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.