Healthcare Claims Operations Manager

Gainwell Technologies LLC; Ohio; À distance; USD 87 000 - 124 000; Plein temps

Résumé du poste

Gainwell Technologies LLC in the United States is seeking a Manager, Service Delivery – CEF Center of Excellence to lead strategies that drive operational excellence across Medicaid claims processing, including mailroom, data entry, and claims issue resolution.

You will partner with Operations, Compliance, IT, and clients to embed standardized, data-driven processes, ensure regulatory alignment, and deliver measurable performance improvements through planning, execution, and governance.

Qualifications

• 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 and drive insights.
• Experience with data and reporting tools (e.g., Excel, Power BI) and applying insights to improve operations.
• Proven ability to lead cross-functional initiatives across operations, compliance, and IT in a healthcare payer environment.
• Knowledge of Medicaid claims processing, CMS guidelines, and coordination of benefits workflows.
• Excellent communication and stakeholder management skills, with experience influencing senior leadership.

Responsabilités

• Lead initiatives to optimize end-to-end claims lifecycle, including mailroom intake, data entry, and adjudication.
• Design and implement process standardization and best practices across claim streams.
• Develop and execute claims operations strategies to improve accuracy, turnaround time, and cost efficiency.
• Analyze claims data and denial trends to identify root causes and opportunities for improvement.
• Define business and technical requirements to support mailroom and claims operations, systems, workflows, and compliance.
• Develop reporting frameworks, dashboards, and KPI structures to drive operational visibility and performance.
• Partner with product and engineering teams to ensure systems meet business and reporting needs.
• Support governance, executive reporting, roadmap planning, and strategic initiatives.
• Drive continuous improvement initiatives using data analytics, process improvement methodologies, and automation opportunities.

Connaissances

Medicaid operations

Data analysis

Cross-functional collaboration

Stakeholder management

Outils

Excel

Power BI

Description du poste

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.

Summary

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.

Your role in our mission

• 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

What we're looking for

• 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 communication and stakeholder management skills, with experience influencing senior leadership and external partners

What you should expect in this role

• This is a full-time permanent regular salaried (W-2) employee position.
• Possible quarterly travel for onsite meeting with team.
• This position will remain posted to take applications until October 26, 2026.

#LI-LM1

#LI-REMOTE

The pay range for this position is $86,700.00 - $123,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.