Medicaid Claims Operations Manager

Clearance Level Must Currently Possess:

Clearance Level Must Be Able to Obtain:

Job Family:

• Education: Bachelor's Degree in related technical, scientific, business, health or a related discipline
• Required Experience: 5+ years of related experience
• Required Skills and Abilities: Medicaid Operations Leadership Support , Project Management Skills, Provider Enrollment Management Skills and Experience, NCQA CVO knowledge and experience.
• 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).

Job Description:

At General Dynamics Information Technology (GDIT), we support state agencies in streamlining Medicaid Enterprise Systems (MES) by delivering operational efficiency and excellence. 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.

• →Manage and oversee day-to-day MES claims operations, ensuring timely and accurate processing, adjudication, and resolution of Medicaid claims according to guidelines and contractual Service Level Agreements (SLAs).
• →You will act as a thought partner to the leadership team to provide support and counsel for operations management, communications, initiatives and projects.
• →You should be a self-starter with outstanding organization and communication skills; fast-paced environment.
• →Understand strategic financials regarding areas of oversight.
• →Proven ability to build strong partnerships with colleagues, desire to be flexible and think proactively, strategically, and analytically about diverse business solutions and leading professional working groups.
• →Ability to make critical decisions with limited guidance while ensuring visibility into those decisions.
• →A demonstrated understanding of Medicaid support operations and an appreciation for how to prioritize among demands and balance the levers that make a complex business run smoothly and productively.
• →Manages Provider Enrollment 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.
• →Serve as lead cross departmental deliverables for operations, including internal and external audits, business continuity, and other program operations deliverables.
• →Serve as a resource for operational managers and assist with training and mentoring operational managers regarding key operational processes.
• →Lead cross departmental operational efforts for internal and external quality assessments, audits and surveys.
• →Lead cross departmental communication initiatives to both internal and external stakeholders, including community engagement efforts and efforts to facilitate employee engagement.
• →Manage and oversee key departments, including training and operational data efforts to optimize efficiencies and ensure effective operations.
• →Oversee and coordinate NCQA CVO efforts and all supporting efforts.
• →Manages and optimizes customer and key stakeholder relationships, including escalations and developing processes to facilitate timely management of provider enrollment related escalations.

Work visa sponsorship will not be provided for this position.

Work Location:

Additional Work Locations:

gdit.com/tc.