Director of Managed Care Operations

Exemption Status: Exempt

Hiring Range: $ - $

Schedule Details: Monday through Friday

Scheduled

Hours:

8:30 AM - 5PM

Shift: 1 - Day Shift, 8 Hours (United States of America)

Hours: 40

This position may have a signing bonus available. A member of the Recruitment Team will confirm eligibility during the interview process.

At UMass Memorial Health, everyone is a caregiver – regardless of title or responsibilities. Exceptional patient care, academic excellence and leading‑edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where you can build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other.

Every person plays an important part, every day.

The Director provides executive‑level leadership and oversight for all managed care operational activities across the UMass Memorial Health system, including UMass Memorial Medical Center, UMass Memorial Medical Group, member hospitals, and all affiliated ancillary providers. The Director serves as the primary system‑wide liaison to managed care plans, ensuring seamless communication and compliance with contractual requirements. The role leads the implementation of new and evolving payment models, resolves complex operational issues, and represents Managed Care Operations in senior‑level committees and cross‑functional initiatives.

Strategic & Operational Leadership

• Lead the design, execution and continuous improvement of managed care operational strategies across the UMMHC system.
• Direct implementation planning for new contracts, payment model transitions and risk‑based arrangements.
• Serve as the authoritative resource on managed care operational requirements, ensuring alignment between payer expectations and internal workflows.
• Anticipate operational impacts of regulatory, contractual or market changes and proactively develop mitigation strategies.

Payor Relations & Contract Operations

• Act as the primary liaison with all contracted health plans, ensuring timely communication, issue resolution and operational compliance.
• Customize operational protocols to reflect payor contractual requirements and evolving plan policies.
• Lead cross‑functional work groups to operationalize new payer programs, benefit designs and population‑specific initiatives (e.g., Dual Eligible Demonstration Projects, specialty pharmacy programs).

Claims, Enrollment & Appeals Oversight

• Oversee monthly claims operations and medical management meetings, ensuring timely resolution of escalated issues.
• Provide direction to internal departments on complex claims, provider enrollment barriers and appeals.
• Develop and monitor performance metrics geared toward improving claims accuracy, reducing denials and enhancing reimbursement.

People Leadership & Organizational Development

• Directly supervise Managed Care Operations staff, including hiring, training, performance evaluations and professional development.
• Foster a culture of accountability, collaboration and continuous improvement.
• Promote diversity, equity and inclusion in hiring and team development.

Financial & Performance Management

• Evaluate operational performance, identify improvement opportunities and implement data‑driven solutions.
• Partner with finance, contracting and clinical leadership to assess the financial impact of operational changes and payer policies.

Compliance, Quality & Regulatory Oversight

• Ensure compliance with all regulatory agencies (e.g., Joint Commission, DPH) and internal policies.
• Maintain and update departmental procedures to meet evolving regulatory and payor requirements.
• Lead or participate in performance improvement initiatives, embedding quality improvement principles into daily operations.