Director of Managed Care Operations in Worcester, Massachusetts at UMass Memorial Health

Description:

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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.
• Promote diversity, equity, and inclusion in hiring, and team development.

Financial & Performance Management

• Evaluate operational performance, identify improvement opportunities, and implement data-driven solutions.
• Partner with finance, contracting, and clinical leadership to assess the financial impact of operational changes and payer policies.

Compliance, Quality & Regulatory Oversight

• Ensure compliance with all regulatory agencies (e.g., Joint Commission, DPH) and internal policies.
• Maintain and update departmental procedures to meet evolving regulatory and payor requirements.
• Lead or participate in performance improvement initiatives, embedding quality improvement principles into daily operations.

Standard Management Level Responsibilities:

1. Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.

2. Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.

3. Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.

4. Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation; and fosters the effective integration of efforts with system-wide initiatives.

5. Encourages and supports diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, respect, tolerance, civility and acceptance toward all employees, patients, and visitors.

6. Integrates diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc.

7. Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.

8. Ensures compliance with regulatory agencies such as Joint Commission, DPH (Department of Public Health), etc. Develops and maintains procedures necessary to meet regulatory requirements.

9. Ensures that department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures.

10. Ensures adequate equipment and supplies for department.

11. Develops and maintains established departmental policies, procedures, and objectives.

12. Ensures compliance to all health and safety regulations and requirements.

13. Maintains, regular, reliable, and predictable attendance.

14. Performs similar or related duties as required or directed. All responsibilities are essential job functions.

Position Qualifications

License/Certification/Education

Required

• Bachelor’s degree in Business Administration, Healthcare Management, or related field.

Preferred

• Master’s degree in Healthcare Administration, Business, Public Health, or related discipline.

Experience/Skills

Required

• Experience working within both health plan and hospital system environments.
• Minimum of 10 years of experience in a managed care setting, with deep knowledge of clinical operations, healthcare terminology, and managed care policy. The document states: “Must have 10 year’s experience in Managed Care setting; thorough understanding of clinical operations, health care terminology, and managed care policy.”
• Demonstrated leadership experience managing teams and complex operational functions.
• Exceptional communication, negotiation, and relationship‑building skills.

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents.

Physical & Work Environment

• Work is primarily sedentary and performed in a standard office environment.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.

About Us:

At UMass Memorial Health, everyone is a caregiver. No matter their responsibilities or title, every employee or "caregiver" fills an important role for our patients and their families every day. Who is a caregiver? It's not just the person who delivers the care. It's all the people who make it work ... and make it better. Caregivers give everything that helps patients heal, from expertise to extra attention. They give clean, comfortable rooms. Fast, accurate answers. And an easier, less stressful experience. They give warm, reassuring smiles, and helping hands. We are more than 16,000 employees, working together as one health system in a relentless pursuit of healing for our patients, our community and each other. And everyone, in their own unique way, plays an important part, every day.