Operations

• Manage daily Maryland Medicaid claims operations to ensure timely and accurate claims adjudication and payment
• Direct and support claims supervisors, auditors, and analysts; provide coaching, workload direction, and performance management
• Oversee inventory levels, turnaround times (TAT), backlog reduction, reduction of claims interest, suspended claims work queues, and provider dispute resolution
• Drive improvements in auto-adjudication rates, accuracy, and first-pass resolution
• Ensure all claims processes comply with State Medicaid regulations and billing guidelines, CMS requirements and Federal managed care rules, Timely filing laws and encounter data reporting requirements
• Support readiness reviews, audits, Corrective Action Plans (CAPs), and state submissions
• Implement QA programs to monitor claim accuracy, provider payment integrity, and policy adherence
• Review and analyze claims performance dashboards, error trends, and key metrics (TAT, payment accuracy, denial rates, encounters, etc.)
• Partner with Finance on claims reserves, cost-of-care reporting, and reconciliation issues
• Work closely with Configuration, Cotiviti and Claim Xten to resolve system issues, benefit configuration errors, and pricing or editing defects
• Partner with Provider Relations to address contractual interpretation questions and recurring provider submission issues
• Collaborate with Utilization Management/Medical Management on authorization-related claims issues
• Coordinate with Compliance and Legal on regulatory changes and required process updates
• Lead initiatives to streamline workflows, automate processes, reduce manual interventions, and improve accuracy
• Drive root-cause analysis and implement sustainable corrective actions
• Participate in the development of policy and procedure updates for Medicaid claims operations

Claims Operations Manager

Operations Manager

Senior Planning & Operations Specialist

Director, Care Operations

Director, Operations Analytics – Workforce Optimization

Vice President, Delivery & Deployment Operations