Commercial Claims Operations Manager

Site: 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.

 

 

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.

 

• 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 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.

 

Hybrid

 

399 Revolution Drive

 

40

 

Regular

 

Day (United States of America)

Pay Range

$99,465.60 - $141,804.00/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, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

 

Mass General Brigham Competency Framework