Director, Claims Management

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

📋 Description

• Oversee the medical claims operations for the designated third-party administrator, adhering to client service level agreements.

• Ensure that claims are processed with precision and within the stipulated timeframes.

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

• Achieve and maintain client SLAs, ensuring processing timelines of approximately 21 to 45 days or within 30 days of receiving clean claims.

• Take ownership of SLA tracking and respond proactively when standards are at risk.

• Develop a framework for traditional medical claims administration tailored for self-funded employer plans.

• Lead Client Managers, Team Leads, and Coordinators across the designated teams.

• Manage workload distribution, escalations, performance evaluations, recruitment, and staff development.

• Oversee vendor relationships related to clearinghouse, cost containment, medical review, staffing, and associated functions.

• Supervise vendor performance and address disputes and issues as they arise.

• Create hiring and staffing strategies, fulfill approved positions, and enhance bench strength.

• Manage operational projects including system updates, reporting modifications, vendor implementations, and go-lives.

• Analyze claims data to uncover trends, issues, and opportunities, implementing data-driven enhancements.

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

• Ensure compliance with healthcare regulations, including ERISA, COBRA, HIPAA, and scope-of-practice requirements.

• Maintain superior client service and resolve operational client concerns effectively.

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

• Report directly to the VP of Operations.

• Travel occasionally as necessary.

⛳️ Requirements

• Bachelor's degree in Business Administration, Healthcare Management, or a related discipline, or equivalent experience.

• A minimum of 7 years' experience in medical claims management.

• At least 3 years in a leadership position within a TPA or health insurance setting.

• Proven capability to lead and inspire a claims team, manage vendor relationships, and oversee hiring and staffing across multiple teams.

• Demonstrated operational leadership in a TPA or medical claims operation that complies with client SLAs.

• Strong people leadership skills for managing Managers, Team Leads, and Coordinators.

• Proficient in vendor management.

• Excellent verbal, written, and interpersonal communication abilities.

• Outstanding analytical and problem-solving skills.

• Strong time management capabilities.

• Must be a self-motivated individual comfortable with significant accountability.

• Ability to adapt effectively to change and shifting priorities.

• Proficient in Google Suite, particularly in Documents and Sheets, Gmail, and Calendar.

• Comfortable using Salesforce as the system of record.

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

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

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

• Working knowledge of self-funded employer plan administration.

• Familiarity with HCSM Needs adjudication is advantageous.

• Ability to stay informed about healthcare regulations, insurance, cost-sharing rules, and industry best practices.

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

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional growth and career development.

• Flexibility to work remotely.