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Exemption Status:

Exempt

Hiring Range:

$101,025.60 - $181,854.40

Please note that the final offer may vary within this range based on a candidate’s experience, skills, qualifications, and internal equity considerations.

Schedule Details:

Monday through Friday

Scheduled Hours:

8:30 AM - 5PM

Shift:

1 - Day Shift, 8 Hours (United States of America)

Hours:

40

Cost Center:

99940 - 5876 Payer Contracting

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

The Director, Managed Care Operations provides executive-level leadership and oversight for all managed care operational activities across the UMass Memorial Health (UMMHC) system, including UMass Memorial Medical Center, UMass Memorial Medical Group, member hospitals, and all affiliated ancillary providers. The Director serves as the primary system-wide liaison to managed care plans, ensuring seamless communication, operational alignment, and compliance with contractual requirements.

This role leads the implementation of new and evolving payment models, oversees resolution of complex operational issues, and represents Managed Care Operations in senior-level committees and cross-functional initiatives. The Director is the primary liaison with managed care plans relative to communication and implementation of all applicable plan policies and procedures and resolution of operations issues arising under the system’s managed care contracts. The Director also leads quarterly operations meetings with member hospitals and plays a key role in system-wide initiatives such as utilization review, specialty pharmacy expansion, and new product or service-line implementations.

Major Responsibilities

Strategic & Operational Leadership

• Lead the design, execution, and continuous improvement of managed care operational strategies across the UMMHC system.

• Direct implementation planning for new contracts, payment model transitions, and risk-based arrangements.

• Serve as the authoritative resource on managed care operational requirements, ensuring alignment between payer expectations and internal workflows.

• Anticipate operational impacts of regulatory, contractual, or market changes and proactively develop mitigation strategies.

Payor Relations & Contract Operations

• Act as the primary liaison with all contracted health plans, ensuring timely communication, issue resolution, and operational compliance.

• Customize operational protocols to reflect payor contractual requirements and evolving plan policies.

• Lead cross-functional workgroups to operationalize new payer programs, benefit designs, and population-specific initiatives (e.g., Dual Eligible Demonstration Projects, specialty pharmacy programs).

Claims, Enrollment & Appeals Oversight

• Oversee monthly claims operations and medical management meetings, ensuring timely resolution of escalated issues.

• Provide direction to internal departments on complex claims, provider enrollment barriers, and administrative or clinical appeals.

• Develop and monitor performance metrics geared toward improving claims accuracy, reducing denials, and enhancing reimbursement..

People Leadership & Organizational Development

• Directly supervise Managed Care Operations staff, including hiring, training, performance evaluations, and professional development.

• Foster a culture of accountability, collaboration, and continuous improvement.

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