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As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
The Manager of Claims Management is responsible for overseeing Medicaid claims operations, inventory management, quality assurance, and compliance monitoring. This role ensures timely and accurate processing of Medicaid claims in accordance with state and federal regulations, contractual requirements, and organizational performance standards. The manager partners cross-functionally with Provider Relations, Configuration, Compliance, Finance, Appeals and Grievance. and Medical Management.
Key Responsibilities
Manage dailyMarylandMedicaid claims operations to ensuretimelyandaccurateclaimsadjudication 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 (not sure of what this is) , and provider dispute resolution.
Drive improvements in auto-adjudication rates, accuracy, and first-pass resolution.
Ensure all claims processescomply with:
State Medicaid regulations and billing guidelines
CMS requirements and Federal managed care rules
Timelyfilinglaws and encounter data reporting requirements
Support readiness reviews, audits, Corrective Action Plans (CAPs), and state submissions.
Implement QA programs tomonitorclaim 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.
Workclosely with Configuration,Cotiviti and ClaimXtento 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 andrequiredprocess 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.
Required Qualifications
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 driveperformance andoptimizeoperational workflows.
Analytical skills withproficiencyin Excel and claims data analysis.
Job responsibilities are not limited to the description above.
Preferred Qualifications
Experience with Medicaid managed care organizations (MCOs) or state Medicaid agencies.
Knowledge of fee schedules, and Medicaid pricing methodologies.
Background in payment integrity, claims audits, configuration testing, or encounter operations.
Lean Six Sigma or process improvement certification.
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$66,330.00 - $145,860.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 11/29/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
