Manager, Medicaid Policy – Operations

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee state Medicaid fee schedules, rate adjustments, public meeting agendas, and program criteria across various U.S. Medicaid systems to detect changes that could impact reimbursement and operational performance. This includes researching and compiling reimbursement requirements necessary for the implementation of new coverage as it becomes effective.

• Act as an internal expert on state-specific Medicaid reimbursement protocols, encompassing EPSDT processes, documentation standards, as well as prior authorization and claims submission considerations.

• Collaborate closely with Medicaid Policy Directors in Market Access to facilitate the submission of policy change requests and manage issue escalation within Medicaid agencies, assisting in the preparation of materials and uncovering state-specific procedures.

• Assist Regional Market Access Directors by aggregating data, conducting research, and providing supportive resources to inform focused reimbursement and contracting strategies for priority out-of-network payers.

• Maintain a centralized record of Medicaid reimbursement challenges, payment discrepancies, policy inquiries, and escalation requirements, including updates on statuses, ownership, and subsequent steps.

• Convert state Medicaid policies and reimbursement criteria into straightforward, actionable guidance for the Revenue Cycle Team to ensure accurate and uniform execution.

• Evaluate claims data, denial patterns, payment discrepancies, and prior authorization results to pinpoint root causes, highlight reimbursement insights, and propose data-informed process enhancements for Market Access and Revenue Cycle collaborators.

• Create and sustain state- and payor-specific standard operating procedures, reference documents, and workflows aimed at improving consistency and minimizing rework.

• Integrate reimbursement insights and operational trends into recommendations for Market Access leadership to guide prioritization, escalation, and strategic decision-making.

⛳️ Requirements

• A Bachelor’s degree in healthcare, public policy, business, or a related discipline is preferred.

• 4–7+ years of experience in Medicaid policy or operations.

• Experience within a Medicaid agency or managed care organization is strongly preferred.

• Direct experience with EPSDT programs is strongly preferred.

• Proficiency in analyzing claims data and identifying factors contributing to denials or variability in reimbursement.

• Capability to utilize claims data, research, and external communications (e.g., Medicaid agencies) to pinpoint root causes and establish standardized processes.

• Excellent analytical, organizational, and communication skills.

• High proficiency in Excel and comfort with claims-level datasets for trend identification, summarizing findings, and supporting data-driven decisions.

🏝️ Benefits

• Competitive compensation and benefits that align with local market norms and legal stipulations.

• Health insurance coverage.

• Retirement plan options.

• Paid time off.

• Flexible working arrangements.

• Opportunities for professional development.