Medicaid Claims Operations Manager

Type of Requisition:
Pipeline

Clearance Level Must Currently Possess:
None

Clearance Level Must Be Able to Obtain:
None

Public Trust/Other Required:
Other

Job Family:
Ancillary Health

Job Qualifications:

Skills:
Claims Operations, Healthcare Claims Processing, Medicaid Claims, Medicaid Policy, People Management
Certifications:
None
Experience:
8 + years of related experience
US Citizenship Required:
No

Job Description:

We are seeking a Claims Operations Manager to oversee and optimize the day-to-day MES claims processing operations under the Fiscal Agent Operations function. This role involves managing the processing, adjudication, and resolution of healthcare claims for Medicaid beneficiaries while ensuring operational compliance and consistent service delivery.

As the Claims Operations Manager, you will lead a team responsible for ensuring that Medicaid claims processing operations meet performance standards, comply with state and federal regulations, and deliver a high degree of accuracy and timeliness.

Responsibilities

• Manage and oversee day-to-day MES claims operations, including staff and other supervisors, to ensure timely and accurate processing, adjudication, and resolution of Medicaid claims according to guidelines and contractual Service Level Agreements (SLAs).
• Builds strong partnerships with colleagues, desires to be flexible and think proactively, strategically, and analytically about diverse business solutions and leading professional working groups.
• Manages claims operations for the program, including optimizing resources to facilitate SLA deliverables and maximize efficient operations. Manages change management efforts and reporting to optimize SLAs and ensure optimization of resources.
• Will be the primary point of contact for the state customers and responsible for managing all claims processing operations, including but not limited to: Claims Resolution, Drug Rebate, Medical Policy, Financial Transactions, and Data Entry
• Lead cross departmental operational efforts for internal and external quality assessments, audits and surveys.
• Drives communication initiatives to both internal and external stakeholders, including community engagement efforts and efforts to facilitate engagement.
• Responsible for ensuring operations staff follow defined processes and procedures
• Analysis and report on performance of operations activities
• Primary point of contact for CMS Regulation and State Plan Policies

Required Skills and Qualifications

• Education: Bachelor's Degree in related technical, scientific, business, health or a related discipline (or equivalent work experience)
• Required Experience: Eight (8) years of experience managing Medicaid or Major Health Care Payer Claims processing
• Required Skills and Abilities:
  • Medicaid Operations Leadership Support
  • Project an people management skills.
  • Knowledge and experience related to state Medicaid systems support and operations/administration, especially related to claims processing.
  • Demonstrated ability to communicate issues, impacts, and corrective actions
• Preferred Skills:
  • SharePoint, Excel, PMO, PowerPoint
  • Strong knowledge of Medicaid Fee-for-Service (FFS), and Managed Care claims processes.
  • Experience with healthcare claims software platforms and operational workflows.
  • Experience in claims repricing and interaction with national coding standards (e.g., CPT, ICD-10, HCPCS).
  • Familiarity with Program Integrity (PI) workflows, fraud/waste/abuse detection, and encounter data validation.
  • Proficiency with claims adjudication systems, reporting tools, and analytics platforms like Tableau or Power BI.
  • Familiarity with Medicaid Information Technology Architecture (MITA) and CMS certification processes.
  • Highly desirable certifications such as Certified Medical Reimbursement Specialist (CMRS) or lean process improvement certifications (e.g., Six Sigma).

Additional Information:

Location: Montgomery, AL.

Security: A fingerprint based background check will be required.

Timeline: This is a contingent job posting. Work is not expected to begin until June 2027 or later.

Work visa sponsorship will not be provided for this position.

Scheduled Weekly Hours:
40

Travel Required:
Less than 10%

Telecommuting Options:
Hybrid

Work Location:
USA AL Montgomery

Additional Work Locations:

Total Rewards at GDIT:
Our benefits package for all US-based employees includes a variety of medical plan options, some with Health Savings Accounts, dental plan options, a vision plan, and a 401(k) plan offering the ability to contribute both pre and post-tax dollars up to the IRS annual limits and receive a company match. To encourage work/life balance, GDIT offers employees full flex work weeks where possible and a variety of paid time off plans, including vacation, sick and personal time, holidays, paid parental, military, bereavement and jury duty leave. To ensure our employees are able to protect their income, other offerings such as short and long-term disability benefits, life, accidental death and dismemberment, personal accident, critical illness and business travel and accident insurance are provided or available. We regularly review our Total Rewards package to ensure our offerings are competitive and reflect what our employees have told us they value most.

Our Identity Verification Process:
As part of the hiring process, we will ask you to complete an identity verification process that leverages advanced biometrics and artificial intelligence to ensure authenticity and protect against identity fraud. You are expected to be on camera during virtual interviews. We reserve the right to take your picture to verify your identity and prevent fraud. By proceeding, you authorize the collection, processing, and use of your biometric data for identity verification and security purposes.