Claims Operations Manager

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Mass General Brigham Health Plan Holding Company, Inc.

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.

Claims Operations Manager, Health Plan The Manager, Claims Operations is a critical role within the Claims Operations areas. We are hiring for two open manager roles;
Medicaid and Commercial lines of business. Each role will oversee a large department of seasoned professionals with a wide array of skills. The ideal candidate will possess excellent communication and organizational ability. They will have a strong aptitude for technology and its impact on claims operations.
** Job Summary
** 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, directing, 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
-Monitors accurate reporting of claim key metrics including but not limited to claim turnaround times, denial rates, quality scores, claims over 30 and 45 days, customer service statistics, call tracking and correspondence inventories and turnaround, data entry numbers, and turnaround time.

-Set clear goals and objectives and use metrics to measure performance and hold staff accountable.

-Provide coaching to improve performance and hold regular development.
-Leads the claims operations team, including hiring, training, and performance management.

-Oversees the processing and submission of claims to ensure accuracy, timeliness, and compliance with payer requirements.

-Monitors claim metrics to identify trends, reduce denials, and improve revenue cycle performance.

-Implements and updates policies and procedures to align with regulatory standards and organizational goals.

-Collaborates with billing, coding, and clinical teams to address claims issues and resolve discrepancies.

-Manages relationships with insurance payers to streamline claims adjudication and reimbursement processes.

-Prepares and presents performance reports and improvement strategies to hospital leadership.
** Qualifications
* ** Bachelor's Degree Healthcare Administration required, or bachelor's degree Business Administration required, or bachelor's degree in a related field of study required
* Certified Professional Coding - Preferred
* Experience in claims management or revenue cycle operations 5-7 years required and Experience in a supervisory or leadership role 2-3 years required

Skills For Succes
* Thorough knowledge of claims processes, insurance requirements, and healthcare regulations.
* Strong leadership and team management abilities.
* Proficiency in claims processing systems and revenue cycle management tools. Excellent analytical skills to assess and improve claims performance metrics.
* Effective communication and interpersonal skills for collaboration and issue resolution.
* Ability to manage multiple priorities in a fast-paced and dynamic healthcare environment.
* Experience in automation implementation and leveraging AI technology to streamline business processes.
* Attention to detail and a commitment to maintaining compliance and accuracy.
** 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
** Hybrid
* * Work Location
** 399 Revolution Drive
** Scheduled Weekly Hours
** 40
* * Employee Type
** Regular
* * Work Shift
** Day (United States of America)
** Pay Range**$97,510.40 - $/Annual
** Grade
* * 8

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable,…