Claims Operations Specialist

Job Description

Job Description

Description:

Title: Senior Specialist, Vendor Performance Management  

Job Type: Full-time  

Location: Hybrid — 4 days per week in Brighton, MA office; 1 day remote  

FLSA Status: Exempt  

About Us  

BrightonOne is a nonprofit social enterprise delivering healthcare, housing, and hope to veterans and military-connected families, with enterprise discipline in service to those who served. 

Position Overview  

The Senior Specialist, Vendor Performance Management supports the day-to-day oversight and accountability of USFHP's vendors, with subject-matter depth in claims. The role manages assigned vendor relationships and performance, partners with technical SMEs to define and operationalize SLAs and accountability plans, and serves as a claims-process subject-matter expert charged with analyzing performance, driving remediation, and helping ensure vendors deliver accurate, timely, compliant service. 

Key Responsibilities  

Vendor Management & Performance Monitoring  

• Manage assigned vendor relationships; monitor performance against SLAs and scorecards and conduct regular operational reviews. 
• Partner with technical SMEs to define, develop, and operationalize vendor accountability plans, requirements, and corrective actions. 
• Track issues and remediation to resolution; support delegation and performance audits with evidence. 

Claims Subject-Matter Expertise  

• Serve as a subject-matter expert on claims processing, adjudication logic, edits, and vendor claims performance. 
• Analyze claims accuracy, timeliness, and financial data to identify issues, root causes, and improvement opportunities. 
• Support claims configuration validation, testing, and issue triage with vendors and internal teams. 

Reporting & Compliance  

• Prepare vendor performance reporting and documentation consistent with TRICARE/USFHP, DHA, and accreditation requirements. 
• Maintain audit-ready records and support governance reporting. 

Cross-Functional Collaboration  

• Partner with operations, compliance, finance, and clinical teams on vendor issues and process improvements. 

Qualifications  

Education & Experience  

• Bachelor's degree preferred, or equivalent experience. 
• 4 or more years of vendor management, claims operations, or health plan operations experience. 
• Claims operations subject-matter expertise strongly preferred. 

Skills & Competencies  

• Strong knowledge of claims processing, adjudication, and vendor/SLA management. 
• Analytical and problem-solving skills; ability to drive vendor accountability. 
• Excellent communication and collaboration with technical subject-matter experts and vendors. 
• Proficiency in Microsoft Office Suite and platforms such as Facets, QNXT, HealthRules, or similar systems. 
• Familiarity with CMS, URAC, NCQA, TRICARE, and healthcare regulatory requirements. 
• Familiarity with CAQH, NPPES, PECOS, and provider credentialing databases. 
• High attention to detail and commitment to data accuracy, with the ability to analyze complex data and identify discrepancies for regulatory compliance. 
• Exceptional organizational and time management skills, with the ability to manage multiple priorities in a fast-paced environment. 
• Experience with Medicare, TRICARE, managed care, or government-sponsored health programs preferred. 

Other Requirements  

• Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment. 

Physical Nature of the Job

Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move throughout the campus. 

Equal Opportunity Employer Statement  

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by federal, state, or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process. 

Work Authorization

Candidates must be authorized to work in the United States without sponsorship now or in the future.