Commercial Claims Operations Manager
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Job Location:
Somerville, NJ - USA
Monthly Salary:
$ 97510 - 141804
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
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.
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.
Qualifications
- Bachelors 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 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. QNXTFacets 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.
Additional Job Details (if applicable)
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.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$97510.40 - $141804.00/AnnualGrade
8EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
Manager
Key Skills
- Forecasting
- Hyperion
- Cost Management
- Construction Estimating
- QlikView
- Bus Driving
- Analysis Skills
- HubSpot
- Salesforce
- Market Research
- negotiation
- Financial Planning
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
