Claims Operations Manager Jobs in Boston, MA (NOW HIRING)

nirvanaHealth is building the payer enterprise on a digital workforce. Our cloud-native Aria platform delivers payer administrative and care-continuum functions as Transaction-as-a-Service (TaaS), combining configurable payer workflows, robotic process automation, machine learning, and agentic AI to execute high-volume transactions consistently while human teams focus on exceptions, member and provider outcomes, and product innovation. Aria supports Commercial, ASO, Medicare Advantage, Medicaid, and ACA lines of business, as well as value-based care arrangements from bundled payments to full-risk and MSO models. We are expanding our product leadership team to deepen payer-domain coverage across Aria and partner with senior engineers to translate payer operations into platform workflows, business rules, data requirements, and configuration.

Job Summary:

The Product Manager works closely with the Chief Product Officer to support the payer transaction engine on Aria, including claims adjudication, benefit and contract execution, pricing, payment, recoupment, reconciliation, and encounter submission. The role supports product definition for how the Aria digital workforce adjudicates and pays claims at scale, while helping ensure exceptions requiring clinical, operational, or financial judgment are routed to the right human teams.

Job Responsibilities (including but not limited to):

• Work closely with the Chief Product Officer and cross-functional partners to build pricing and reimbursement constructs—fee schedules, contracted rates, capitation (PMPM, % of Premium, CMS-MMR), DOFR, risk pool, bundled payments, and episode-based payments.
• Translate claims operations into the business rules, edits, configuration, data requirements, and exception workflows that the Aria digital workforce executes.
• Help define benefit configuration and provider contract configuration as consumed by the claims engine at run time, including the handoff from product, provider, and network teams.
• Help define auto-adjudication strategy, claims edits, COB logic, payment integrity controls, and exception-routing logic.
• Contribute to payment execution, recoupment, settlement, and claims financial reconciliation workflows, including capitation and delegated-risk execution under value-based arrangements.
• Contribute to encounter submission and correction workflows, including Medicare Advantage, Medicaid, and other applicable state or federal encounter data requirements.
• Partner with senior engineers and implementation teams to convert claims requirements into engineering-ready specifications, UAT plans, regression scenarios, and release-ready documentation.

Qualifications:

1. Education and/or Training:

• Bachelor's degree required; major in business, healthcare administration, technology, or a related field preferred.

2. Professional Experience:

• Solid understanding of pricing and reimbursement constructs—fee schedules, contracted rates, capitation (PMPM, % of Premium, CMS-MMR), DOFR, risk pool, bundled payments, and episode-based payments.
• 5+ years of experience in product management, product ownership, senior business analyst, or implementation lead roles on a payer claims platform, health plan service, or core administrative processing system.
• Hands-on experience with at least two of: claims adjudication, claims edits, benefit configuration, provider contract configuration, payment integrity, encounter submission.
• Working knowledge of one or more payer lines of business — Medicare or Medicare Advantage preferred; Commercial, Medicaid, ACA/Exchange, or ASO/self-funded acceptable.
• Demonstrated track record translating claims operations into engineering-ready requirements.

3. Licenses/Certifications:

• N/A

4. Specialized Skills:

• Strong written and verbal communication; ability to translate complex adjudication logic into clear specifications and decision tables.
• Working familiarity with CMS regulatory requirements relevant to claims and encounter submission.
• Experience authoring SOPs and process documentation used by claims operations, payment integrity, and implementation teams.
• Comfort working directly with senior engineering teams in an Agile or SAFe environment.
• Comfort using generative AI tools to accelerate requirements drafting, workflow mapping, test-case generation, process documentation, and analysis. Deep prior AI experience is not required; curiosity and adaptability are.

5. Technical Skills:

• Comfortable reading X12 claims transaction sets (837, 835), data models, and integration specifications.
• Proficient with Jira/Confluence and structured backlog management.
• Strong PC skills, including MS Word, Excel, and PowerPoint.

6. Additional Considerations:

• Applicants must be able to pass a background investigation; all offers are contingent upon the successful completion of a background check per company policy.

Physical and Mental Requirements:

1. Physical Activities:

• Some travel may be required.

2. Mental Activities:

• General mental activity related to job duties.