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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medicaid claims processing, team supervision, and compliance with CMS regulations. Proficient in performance monitoring, process improvement, and operational management within healthcare settings.
Highest-signal resume keywords
Medicaid Claims Processing ExperienceSupervisory ExperienceClaims Adjudication KnowledgePerformance Metrics MonitoringLean or Six Sigma Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationProvider Reimbursement MethodologiesHealthcare OperationsProcess ImprovementWorkflow OptimizationHealthcare BillingCodingReimbursement MethodologiesAnalytical SkillsDecision-Making Skills
Soft Skills
CoachingProblem-SolvingInterpersonal CommunicationWritten CommunicationVerbal Communication
Tools & Technologies
Microsoft 365OutlookExcelWordPowerPointTeamsMedicaid Management Information System (MMIS)
Industry Keywords
CMS RegulationsMedicaid PoliciesHIPAA RequirementsQuality StandardsService Level AgreementsKey Performance IndicatorsGovernment Healthcare ProgramsPublic Sector Contracts
About the role
Key responsibilities & impact- Supervise, coach, and develop a team of Medicaid claims processors, analysts, and support staff
- Monitor daily claims processing activities to ensure timely, accurate, and compliant adjudication of Medicaid claims
- Manage escalated claims issues, Tier 3 claims escalations, payment discrepancies, provider concerns, and operational exceptions
- Ensure achievement of service level agreements, key performance indicators, quality standards, and contractual requirements
- Review operational reports and performance metrics to identify trends, risks, and improvement opportunities
- Investigate and resolve escalated claims issues, payment discrepancies, and provider inquiries
- Support quality assurance activities, audits, corrective action plans, and process improvement initiatives
- Ensure compliance with CMS regulations, state Medicaid policies, HIPAA requirements, and operating procedures
- Coordinate with internal departments, state agencies, providers, and client stakeholders to resolve operational issues
- Support workforce planning, scheduling, training, and employee development activities
- Maintain documentation, operational procedures, and workflow standards
- Participate in system enhancements, testing activities, and special projects
Requirements
What you’ll need- Bachelor's degree in Healthcare Administration, Business Administration, Public Health, or related field; or equivalent combination of education and experience
- Minimum of three (3) years of Medicaid claims processing experience
- Minimum of two (2) years of supervisory, team lead, or leadership experience
- Knowledge of claims adjudication, provider reimbursement methodologies, and healthcare operations
- Experience monitoring performance metrics, productivity standards, quality measures, and service levels
- Strong analytical, problem-solving, and decision-making skills
- Excellent written, verbal, and interpersonal communication skills
- Proficiency with Microsoft 365 applications, including Outlook, Excel, Word, PowerPoint, and Teams
- Experience supporting a Medicaid Management Information System (MMIS) environment preferred
- Knowledge of CMS regulations, Medicaid State Plan requirements, and healthcare industry standards preferred
- Experience managing claims resolution, provider communications, appeals, adjustments, or reimbursement activities preferred
- Prior experience supporting government healthcare programs or public sector contracts preferred
- Experience leading process improvement, workflow optimization, and operational transformation initiatives preferred
- Lean, Six Sigma, or quality management experience preferred
- Knowledge of healthcare billing, coding, and reimbursement methodologies preferred
Benefits
Comp & perks- Health and welfare benefits starting on the first day of employment
- Retirement savings plan
- Employee discounts on merchandise, services, travel, and more
- Career growth opportunities
- Paid training
- Paid time off
- Health insurance coverage
- Voluntary dental and vision programs
- Life and disability insurance
- Paid holidays
- Bonus or incentive eligibility based on business need
- Hybrid work arrangement
- Award-winning learning platforms
- Great work environment and diversity-focused culture