Healthcare Claims Operations Manager

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Date:
Oct 17, 2026

Location:

Any city, TX, US, 99999

Work Mode:
Virtual (Exception only)

Be part of a team that unleashes the power of leading-edge technologies to help improve the health and well-being of those most vulnerable in our country and communities. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work flexibility, learning, and career development. You’ll add to your technical credentials and certifications while enjoying a generous, flexible vacation policy and educational assistance.

We also have comprehensive leadership and technical development academies to help build your skills and capabilities.

The Manager, Service Delivery – CEF Center of Excellence serves as a key leader responsible for developing and executing strategies that drive operational excellence across Medicaid claims processing, including mailroom, data entry and claims issue resolution workflows. This role ensures accurate, compliant, and timely claims processing aligned with CMS and state Medicaid requirements while optimizing efficiency, reducing rework, and improving provider and member experience.

The Manager partners cross-functionally with Operations, Compliance, IT, and Client stakeholders to embed standardized, data-driven processes and ensure alignment with regulatory requirements, payer-specific rules, and organizational policies. This role is accountable for identifying operational risks, improving claims automation, reducing manual claims efforts, and delivering measurable performance improvements through strategic planning and execution.

• Lead initiatives to optimize end-to-end claims lifecycle, including mailroom intake, data entry, reduce manual touches in claims adjudication and adjustment processing.
• Design and implement process standardization and best practices across institutional and professional claim streams
• Develop and execute claims operations strategies to improve accuracy, turnaround time, and cost efficiency across Medicaid workflows
• Analyze claims data, denial trends, and process steps to identify root causes, systemic issues, and opportunities for improvement
• Defining business and technical requirements to support mailroom and claims operations, systems, workflows, and compliance
• Developing reporting frameworks, dashboards, and KPI structures to drive operational visibility and performance
• Partnering with product and engineering teams to ensure systems and data capture meet business and reporting needs
• Supporting Design, Development and Implementation (DDI) efforts to ensure alignment with enterprise standards and data requirements
• Supporting governance, executive reporting, roadmap planning, and strategic initiatives.
• Drive continuous improvement initiatives using data analytics, process improvement methodologies, and automation opportunities
• Establish and maintain operational playbooks and governance structures for claims processing and issue management

• Five (5) or more years of experience in Medicaid operations, claims management, mailroom intake operations, or business analysis
• Strong analytical and problem-solving skills with the ability to interpret claims data, identify trends, and drive actionable insights, and experience with data and reporting tools (e.g., Excel, Power BI) and applying insights to improve claims operations performance
• Proven ability to lead cross-functional initiatives across operations, compliance, and IT in a healthcare payer environment
• Strong knowledge of Medicaid claims processing, CMS guidelines, and coordination of benefits workflows
• Excellent…