Director Claims Management

This is a fully remote position, open to applicants in Texas.

📋 Description

• Take complete responsibility for the designated claims operation, ensuring precise and prompt claims processing while formulating strategies, staffing, and enhancing processes as volume increases.

• Manage the two health share Needs teams, encompassing intake, clinical review, processing, pay/deny/pend decisions, reimbursements, and runout.

• Achieve and maintain client service level agreements, overseeing SLA tracking and addressing any potential risks to standards.

• Progress towards traditional medical claims administration for self-funded employer plans covering intake, adjudication, repricing, payment, and runout.

• Supervise Client Managers, Team Leads, and Coordinators across the assigned teams.

• Oversee workload distribution, escalations, performance management, recruitment, staffing strategies, and employee development.

• Manage relationships with vendors across clearinghouse, cost containment, medical review, staffing, and related areas.

• Direct operational projects, system and reporting modifications, vendor implementations, and go-live events.

• Examine claims data to uncover trends, issues, and opportunities for improvement.

• Compile and present operational and performance reports to senior leadership.

• Stay informed about healthcare regulations, insurance and cost-sharing guidelines, and industry best practices.

• Ensure operational compliance, including scope-of-practice inquiries for clinical review personnel.

• Uphold high-quality client service while resolving operational client concerns.

• Guarantee adherence to federal and state regulations, including ERISA, COBRA, and HIPAA.

• Collaborate with Compliance, Benefits Administration, Client Services, and other stakeholders on audits, complex claims matters, regulatory updates, and operational excellence.

• Occasional travel may be necessary.

⛳️ Requirements

• Demonstrated operational leadership experience in a TPA or medical claims operation under client SLAs.

• Sound judgment for making director-level decisions regarding escalations and staffing.

• Capacity to lead Managers, Team Leads, and Coordinators, develop staff, and manage performance effectively.

• Experience in vendor management, including enforcing performance standards and resolving conflicts.

• Strong verbal, written, and interpersonal communication abilities.

• Exceptional analytical and problem-solving capabilities using SLA and aging data.

• Proficient time management skills across simultaneous operations, projects, and staffing tasks.

• Self-motivated individual comfortable with extensive accountability in a developing claims operation.

• Flexibility to adapt to changes and modify priorities as needed.

• Proficiency in Google Suite, including advanced skills in Documents and Sheets, Gmail, and Calendar.

• Comfortable using Salesforce as the primary system of record.

• 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 of leadership experience within a TPA or health insurance environment.

• Proven ability to lead and inspire a claims team, manage vendors, and oversee hiring and staffing for a multi-team operation.

• In-depth operational knowledge of third-party medical claims administration and the complete claims lifecycle.

• Expertise in clean-claim/clean-receipt processing-clock rules.

• Familiarity with medical terminology, ICD-10 and CPT codes, and claims adjudication logic.

• Understanding of clearinghouse, cost containment, repricing, medical review, claims management software, and vendor integrations.

• Working knowledge of self-funded employer plan administration.

• Competent in Salesforce and Google Suite.

• Familiarity with HCSM Needs adjudication is advantageous but can be acquired in the role.

• Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, but not mandatory.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional growth and development.

• Flexibility for remote work.

• A dynamic and innovative work environment.

• Reasonable accommodation for qualified individuals with disabilities during the employment application process.