Commercial Claims Operations Manager
$97.51k/y-$141.80k/y
a day ago
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HybridFull-timeSenior
Summary
Mass General Brigham is seeking a Commercial Claims Operations Manager to join their team in Somerville, MA. The role involves managing commercial claims operations to ensure efficient and accurate processing of claims.
About the Role
As a Commercial Claims Operations Manager, you will oversee claims workflows, compliance, and team performance to support revenue cycle goals and optimize reimbursement processes. You will lead daily operations for claims review and resolution teams, manage regulatory compliance, develop performance dashboards, and coach a team of specialists.
About You
Required:
- 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:
- 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.
Benefits
- Comprehensive benefits package including medical, dental, and vision coverage.
- Career advancement opportunities.
- Recognition programs designed to celebrate contributions and support professional growth.
Mass General Brigham
Mass General Brigham is an integrated academic health care system, uniting great minds to solve the hardest problems in medicine for our communities and the world. Mass General Brigham connects a full continuum of care across a system of academic medical centers, community and specialty hospitals, a health insurance plan, physician networks, community health centers, home care, and long-term care services. Mass General Brigham is a nonprofit organization that is committed to patient care, research, teaching, and service to the community. In addition, Mass General Brigham is one of the nation’s leading biomedical research organizations and a principal teaching affiliate of Harvard Medical School.
Somerville, MA