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:
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.
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…