Healthcare Claims Operations Manager

Responsibilities

The manager is responsible for developing and executing strategies to drive operational excellence in Medicaid claims processing, including mailroom and data entry workflows. They will lead cross-functional initiatives to optimize the claims lifecycle, improve accuracy, and reduce manual processing through data-driven process improvements.

Requirements

Candidates must have five or more years of experience in Medicaid operations, claims management, or business analysis. Strong analytical skills and proficiency in data reporting tools are required to drive performance improvements and ensure regulatory compliance.

Skills

• Medicaid operations
• Claims management
• Mailroom intake operations
• Business analysis
• Data analytics
• Process improvement
• Claims adjudication
• CMS guidelines
• Coordination of benefits
• Stakeholder management
• Strategic planning
• Operational excellence
• KPI development
• Automation
• Cross-functional leadership
• Reporting frameworks

Benefits

• Flexible vacation policy
• Educational assistance
• 401(k) employer match
• Comprehensive health benefits
• Leadership development academies
• Technical development academies

About this role

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.

About Gainwell Technologies LLC

IT Services and IT Consulting · 10,001+ employees · headquartered in United States