Remote Medicaid Claims Operations Lead

Gainwell Technologies LLC; United States; Remote; USD 87,000 - 124,000; Full time

Benefits offered by this job

Flexible vacation policy

401(k) employer match

Health benefits

Educational assistance

Job summary

Gainwell Technologies LLC is seeking a Manager, Service Delivery – CEF Center of Excellence to lead end-to-end Medicaid claims operations. You will drive data-driven improvements across mailroom, data entry, and claims adjudication, aligning with CMS and state requirements while boosting accuracy, speed, and member/provider satisfaction.

Collaborating with Operations, Compliance, IT, and clients, you will establish standardized processes, governance, and KPIs, and guide cross-functional teams

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

Responsibilities

• 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

Skills

Analytical thinking

Data interpretation

Cross-functional leadership

Communication

Tools

Excel

Power BI

Job description

Gainwell Technologies LLC is seeking a Manager, Service Delivery – CEF Center of Excellence to lead end-to-end Medicaid claims operations. You will drive data-driven improvements across mailroom, data entry, and claims adjudication, aligning with CMS and state requirements while boosting accuracy, speed, and member/provider satisfaction.

Collaborating with Operations, Compliance, IT, and clients, you will establish standardized processes, governance, and KPIs, and guide cross-functional teams