[Remote] Claims Operations Manager – Maryland Medicaid at CVS Health

Maitland, Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicaid, Health InsuranceIndustries

Requirements

Bachelor’s degree in Business, Healthcare Administration, or related field (or equivalent experience)
3–5+ years of progressive claims experience in Medicaid
Strong understanding of Medicaid billing rules, HSCRC, provider types, benefit structures, and encounter reporting
Experience with major claims systems (e.g., QNXT)
Problem solving mindset; adaptable, ability to analyze processes
Proven ability to drive performance and optimize operational workflows
Analytical skills with proficiency in Excel and claims data analysis

Responsibilities

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

Skills

Key technologies and capabilities for this role

Claims ManagementMedicaid OperationsQuality AssuranceCompliance MonitoringInventory ManagementClaims AdjudicationProvider RelationsPerformance ManagementAuto-AdjudicationCMS RegulationsState RegulationsAudit SupportCorrective Action PlansProvider Dispute ResolutionTurnaround Time Management

Questions & Answers

Common questions about this position

What is the employment type for this Claims Operations Manager role?

This is a full-time position.

Is this Claims Operations Manager role remote or office-based?

This information is not specified in the job description.

What are the key responsibilities for the Claims Operations Manager?

The role involves managing Maryland Medicaid claims operations, overseeing inventory and turnaround times, ensuring compliance with regulations, directing supervisors and analysts, and partnering cross-functionally with teams like Provider Relations, Finance, and Compliance.

What is the company culture like at CVS Health?

CVS Health emphasizes building a world of health with dedicated, purpose-driven colleagues passionate about transforming health care in a connected, convenient, and compassionate way.

What qualifications are required for the Claims Operations Manager position?

A Bachelor’s degree is required.

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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