Director Claims Management
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Director leading TPA medical claims operations for Health Admins, a technology-driven healthcare administration platform. Managing teams, vendors, SLAs, compliance, and claims-processing improvements.
Responsibilities:
- Own full accountability for the assigned claims operation, ensuring accurate and timely claims processing and developing strategies, staffing, and process improvements as volume grows
- Run the two health share Needs teams, including intake, clinical review, processing, pay/deny/pend determinations, reimbursements, and runout
- Meet and sustain client service level agreements and own SLA tracking and responses when standards are at risk
- Build toward traditional medical claims administration for self-funded employer plans across intake, adjudication, repricing, payment, and runout
- Lead Client Managers, Team Leads, and Coordinators across assigned teams
- Own workload distribution, escalations, performance management, hiring, staffing plans, and staff development
- Manage vendor relationships across clearinghouse, cost containment, medical review, staffing, and related functions
- Oversee operational projects, system and reporting changes, vendor implementations, and go-lives
- Analyze claims data to identify trends, issues, and improvement opportunities
- Prepare and present operational and performance reports to senior leadership
- Maintain knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practices
- Own operational compliance, including scope-of-practice questions for clinical review staff
- Maintain high-quality client service and resolve operational client issues
- Ensure compliance with federal and state regulations, including ERISA, COBRA, and HIPAA
- Partner with Compliance, Benefits Administration, Client Services, and other stakeholders on audits, complex claims issues, regulatory changes, and operational excellence
- Occasional travel may be required
Requirements:
- Proven operational leadership of a TPA or medical claims operation under client SLAs
- Judgment to make director-level decisions on escalations and staffing
- Ability to lead Managers, Team Leads, and Coordinators, develop staff, and manage performance
- Vendor management experience, including enforcing performance standards and resolving disputes
- Excellent verbal, written, and interpersonal communication skills
- Exceptional analytical and problem-solving skills using SLA and aging data
- Strong time management across concurrent operations, projects, and staffing work
- Self-starter comfortable with broad accountability in a growing claims operation
- Ability to adapt to change and adjust priorities
- Proficiency with Google Suite, including expert-level Documents and Sheets, Gmail, and Calendar
- Comfort operating in Salesforce as the system of record
- Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience
- Minimum 7 years of experience in medical claims management
- At least 3 years of leadership experience 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
- Deep operational knowledge of third-party medical claims administration and the full claims lifecycle
- Command of clean-claim/clean-receipt processing-clock rules
- Command of medical terminology, ICD-10 and CPT codes, and claims adjudication logic
- Familiarity with clearinghouse, cost containment, repricing, medical review, claims management software, and vendor integrations
- Working understanding of self-funded employer plan administration
- Working proficiency in Salesforce and Google Suite
- Familiarity with HCSM Needs adjudication is helpful but can be learned in role
- 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
- Dynamic and innovative work environment
- Reasonable accommodation for qualified individuals with disabilities in the employment application process
Similar Jobs
Senior Director
Senior Director leading Best Buddies’ national programs for people with intellectual and developmental disabilities. Expanding education, employment, independent living, credentialing, and community-engagement pathways.
Senior Director, Friendship Programs
Senior Director leading Best Buddies’ friendship programs for people with intellectual and developmental disabilities. Expanding chapters, managing volunteers and staff, and strengthening mission delivery.
Director, Site Start Up
Director leading site start-up operations for Precision for Medicine, a clinical research organization. Guiding global trial start-up delivery, regulatory submissions, contracts, risk management, and team development.
Senior Director, Specialty Insights
Senior Director leading Specialty Insights programs for Cencora, a global pharmaceutical solutions company. Managing healthcare market research, KOL relationships, budgets, teams, and client-facing delivery.
Senior Director, Change Management Activation Lead
Senior Director driving change adoption for Cencora, a global pharmaceutical solutions company. Leading organizational readiness, governance, communications, and sustained behavior change across digital transformation initiatives.
Director – National Accounts
Grainger national accounts director leading MRO solutions for complex IFM and Hospitality customers. Developing contract strategy, major-account processes, and multi-site opportunities across the Western United States.
Director, National Accounts
National Accounts Director leading Grainger, a broad-line MRO distributor,’s multi-site sales strategy. Developing major-account processes, closing complex deals, and driving revenue across Western US territory.
Director of Advocacy
Director of Advocacy shaping federal healthcare policy for Pivotal Health’s reimbursement platform. Engaging agencies, Congress, and healthcare stakeholders while building strategic government affairs operations.
Director, US Market Access Strategy, Immunology
Novartis immunology market access director shaping US strategies for innovative medicines. Developing access plans, forecasts, budgets, and commercialization research across cross-functional teams.
Director
California Director building statewide organizing, membership, and coalition strategies for a racial and economic justice movement of local elected officials. Supervising staff, developing leaders, and leading fundraising.
Client Director – New Business
New Business Client Director selling Centrilogic’s Cloud/IT solutions to U.S. and Canadian enterprises. Self-sourcing pipeline, engaging executives, and closing complex services deals.
Director, Strategic Accounts – Specialty Oncology
Strategic oncology accounts director advancing enterprise diagnostics partnerships for Labcorp. Leading national health-system sales, portfolio growth, and oncology strategy across the Atlantic territory.
Director, Strategic Accounts – North East
Strategic oncology accounts director advancing enterprise diagnostics partnerships for Labcorp. Leading health-system sales, executive relationships, and multi-site oncology solutions across the Northeast.
Senior Director, Health System – Specialty Diagnostics Strategy
Senior Director shaping Labcorp’s digital diagnostics strategy for U.S. health systems. Driving EHR, portal, and specialty-testing adoption through enterprise commercial strategy.
Director, Acquisition
Director of Acquisition scaling Meta and TikTok campaigns for AG1, a foundational nutrition company. Managing paid social, creative testing, attribution, and unit economics to grow subscription and CPG sales.
Director, Global Talent – Learning
Director building Chromalloy’s global talent, learning, internship, rotational, mentoring, and engagement programs. Supporting aerospace component repair and manufacturing through enterprise development infrastructure.
2D Technical Director
2D Technical Director building Toon Boom Harmony pipelines and automation tools for Glitch Productions. Owning technical infrastructure for its animation studio as the division scales.
Associate Director – Pharmaceutical Development
Pharmaceutical development leader overseeing small-molecule formulation, scale-up, technology transfer, and CDMO operations. Supporting Celcuity’s targeted cancer therapies and global regulatory submissions.
Pricing Director
Pricing Director transforming monetization for Ping Identity’s enterprise cloud identity platform. Designing packaging, AI and usage-based pricing, financial models, and cross-functional rollout strategies.
Service Director – Application Managed Services
Service Director leading EHR application support, ITSM quality, reporting, and continuous improvement for healthcare consulting firm. Managing client delivery, teams, vendors, and service expansion.