Claims Specialist

BrightonOne; Boston (MA); Hybrid; USD 110,000 - 140,000; Full time

Benefits offered by this job

Security clearance eligibility

Job summary

BrightonOne is a nonprofit social enterprise delivering healthcare, housing, and hope to veterans and military-connected families. The Senior Specialist, Vendor Performance Management, will oversee USFHP vendors, drive accountability on SLAs, and provide claims-process subject-matter expertise to ensure timely, accurate, and compliant service.

You will collaborate with operations, compliance, and finance teams, prepare vendor performance reports, and participate in governance activities.

Qualifications

• Bachelor's degree preferred, or equivalent experience.
• 4+ years in vendor management, claims operations, or health plan operations.
• Subject-matter expertise in claims processing and vendor/SLA management preferred.
• Proven analytical and collaborative skills with stakeholders.

Responsibilities

• Oversee vendor relationships and monitor SLAs and scorecards.
• Develop and enforce vendor accountability plans and corrective actions.
• Analyze claims data to identify issues and drive remediation.

Skills

Vendor management

Claims operations

SLA management

Analytical skills

Communication

Education

Bachelor's degree or equivalent

Experience in health plans

Tools

Facets

QNXT

HealthRules

MS Office

Job description

Job Type: Full-time

Location: Hybrid — 4 days per week in Brighton, MA office; 1 day remote

FLSA Status: Exempt

About Us

BrightonOne is a nonprofit social enterprise delivering healthcare, housing, and hope to veterans and military-connected families, with enterprise discipline in service to those who served.

Position Overview

The Senior Specialist, Vendor Performance Management supports the day-to-day oversight and accountability of USFHP's vendors, with subject-matter depth in claims. The role manages assigned vendor relationships and performance, partners with technical SMEs to define and operationalize SLAs and accountability plans, and serves as a claims-process subject-matter expert charged with analyzing performance, driving remediation, and helping ensure vendors deliver accurate, timely, compliant service.

Key Responsibilities

• Manage assigned vendor relationships; monitor performance against SLAs and scorecards and conduct regular operational reviews.
• Partner with technical SMEs to define, develop, and operationalize vendor accountability plans, requirements, and corrective actions.
• Track issues and remediation to resolution; support delegation and performance audits with evidence.

Claims Subject-Matter Expertise

• Serve as a subject-matter expert on claims processing, adjudication logic, edits, and vendor claims performance.
• Analyze claims accuracy, timeliness, and financial data to identify issues, root causes, and improvement opportunities.
• Support claims configuration validation, testing, and issue triage with vendors and internal teams.

Reporting & Compliance

• Prepare vendor performance reporting and documentation consistent with TRICARE/USFHP, DHA, and accreditation requirements.
• Maintain audit-ready records and support governance reporting.

Cross-Functional Collaboration

• Partner with operations, compliance, finance, and clinical teams on vendor issues and process improvements.

Qualifications

Education & Experience

• Bachelor's degree preferred, or equivalent experience.
• 4 or more years of vendor management, claims operations, or health plan operations experience.
• Claims operations subject-matter expertise strongly preferred.
• Strong knowledge of claims processing, adjudication, and vendor/SLA management.
• Analytical and problem-solving skills; ability to drive vendor accountability.
• Excellent communication and collaboration with technical subject-matter experts and vendors.
• Proficiency in Microsoft Office Suite and platforms such as Facets, QNXT, HealthRules, or similar systems.
• Familiarity with CMS, URAC, NCQA, TRICARE, and healthcare regulatory requirements.
• Familiarity with CAQH, NPPES, PECOS, and provider credentialing databases.
• High attention to detail and commitment to data accuracy, with the ability to analyze complex data and identify discrepancies for regulatory compliance.
• Exceptional organizational and time management skills, with the ability to manage multiple priorities in a fast-paced environment.
• Experience with Medicare, TRICARE, managed care, or government-sponsored health programs preferred.

Other Requirements

• Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.

Physical Nature of the Job

Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move throughout the campus.

Equal Opportunity Employer Statement

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by federal, state, or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Work Authorization

Candidates must be authorized to work in the United States without sponsorship now or in the future.