Director, Claims Management
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Job Description
Director leading third-party medical claims operations for Health Admins’ technology-driven healthcare administration platform. Managing SLAs, teams, vendors, compliance, and operational improvement.
Responsibilities:
- Lead the assigned third-party administrator medical claims operation under client service level agreements
- Ensure claims are processed accurately and within required timeframes
- Run the two health share Needs teams, including intake, clinical review, processing, pay/deny/pend determinations, reimbursements, and runout
- Meet and sustain client SLAs, including processing timelines of roughly 21 to 45 days or within 30 days of clean receipt
- Own SLA tracking and responses when standards are at risk
- Build toward traditional medical claims administration for self-funded employer plans
- Lead Client Managers, Team Leads, and Coordinators across assigned teams
- Own workload distribution, escalations, performance management, hiring, and staff development
- Manage vendor relationships across clearinghouse, cost containment, medical review, staffing, and related functions
- Oversee vendor performance and resolve disputes and issues
- Develop hiring and staffing plans, fill approved headcount, and build bench depth
- Oversee operational projects, including system and reporting changes, vendor implementations, and go-lives
- Analyze claims data to identify trends, issues, and opportunities and implement data-driven improvements
- Prepare and present operational and performance reporting to senior leadership
- Maintain compliance with healthcare regulations, including ERISA, COBRA, HIPAA, and scope-of-practice requirements
- Maintain high-quality client service and resolve operational client issues
- Partner with Compliance, Benefits Administration, Client Services, and other internal stakeholders on audits, complex claims issues, regulatory changes, and operational excellence
- Report to the VP of Operations
- Travel occasionally as required
Requirements:
- Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience
- Minimum of 7 years of experience in medical claims management
- At least 3 years in a leadership role in a TPA or health insurance environment
- Demonstrated ability to lead and motivate a claims team, manage vendors, and own hiring and staffing for a multi-team operation
- Proven operational leadership of a TPA or medical claims operation under client SLAs
- Strong people leadership of Managers, Team Leads, and Coordinators
- Vendor management skills
- Excellent verbal, written, and interpersonal communication skills
- Exceptional analytical and problem-solving skills
- Solid time management skills
- Must be a self-starter comfortable operating with broad accountability
- Must adapt well to change and shifting priorities
- Proficiency with Google Suite, including expert-level Documents and Sheets, Gmail, and Calendar
- Comfortable operating in Salesforce as the system of record
- Deep operational knowledge of third-party administration of medical claims and the full claims lifecycle
- Knowledge of medical terminology, ICD-10 and CPT codes, and claims adjudication logic
- Familiarity with clearinghouse, cost containment, repricing, medical review processes, claims management software, and vendor integrations
- Working understanding of self-funded employer plan administration
- Familiarity with HCSM Needs adjudication is helpful
- Ability to maintain knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practices
- Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, not required
Benefits:
- Competitive salary and benefits package
- Opportunities for professional growth and development
- Remote work flexibility
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