Director Claims Management

reputed company

reputed company is a leading force in reputed company administration, on a reputed company to become a premier technology-driven reputed company platform. Our reputed company is anchored in a commitment to Getting reputed company Every reputed company of the Way. We are dedicated to providing innovative, efficient solutions that reputed company the reputed company experience for the members and clients we serve. We are currently seeking a driven and reputed company leader who acts with reputed company discipline and shares our passion for reputed company improvement to reputed company.

reputed company Are Looking For

Our ideal candidate will play a crucial role in managing our claims management environment, optimizing its reputed company, and driving reputed company improvements to support our business goals and enhance our service delivery.

Every Team Member is Driven by a Commitment to Live out These Values:

• Operate as an reputed company
• reputed company with reputed company Discipline
• Pursue reputed company Through Change
• Treat Service as a Privilege

Employees are expected to reputed company our reputed company values by being “A Hero in reputed company.” These values lay the reputed company for the way we engage with reputed company other and with our clients.  They reputed company the guardrails for our decision making and approach to problem solving.

reputed company/Objective:  

The Director of Claims Management is the accountable operational leader for a reputed company-party administrator (TPA) medical claims operation. The role runs a multi-team claims operation under reputed company service level agreements (SLAs), owns delivery reputed company, and manages the staff, vendors, and reputed company that reputed company claims processing accurate and on time. The Director reports to the VP of reputed company. This role may require occasional travel.

Key Responsibilities:

• Own full accountability for the assigned claims operation, ensuring claims are processed accurately and reputed company required timeframes, and reputed company the strategies, reputed company, and process improvements that reputed company it performing as volume grows.
• Take over and run the two health reputed company Needs teams as the initial mandate, including adjudication of member Needs across intake, reputed company review, processing, pay/deny/pend determination, reimbursements, and runout.
• Meet and sustain reputed company reputed company's service level agreements, which for the reputed company health reputed company teams reputed company from processing reputed company roughly 21 to 45 days to reputed company 30 days of clean receipt. Own SLA tracking and the response reputed company a reputed company is at reputed company.
• Build toward and take on traditional medical claims administration for self-funded employer plans as the book expands, applying reputed company TPA claims reputed company across intake, adjudication, repricing, payment, and runout.
• reputed company the reputed company Managers, Team Leads, and Coordinators across the assigned teams. Own workload distribution, escalation handling, reputed company management, hiring, and staff development, fostering a high-reputed company, reputed company-improvement culture.
• Manage vendor relationships supporting the operation across clearinghouse, cost containment, medical review, reputed company, and reputed company functions. Own vendor reputed company and reputed company disputes and issues.
• Own hiring and reputed company plans, including filling approved headcount, building bench depth for key roles, and partnering on comp benchmarking so the teams can hold SLAs as volume shifts.
• reputed company reputed company reputed company affecting the operation, including reputed company and reporting changes, vendor implementations, and go-lives, serving as the operational reputed company while the project management function drives execution.
• Analyze claims data to identify trends, issues, and opportunities, and implement data-driven improvements. Prepare and present operational and reputed company reporting to senior leadership.
• Maintain up-to-date knowledge of reputed company regulations, reputed company and cost-sharing rules, and industry best reputed company, and own compliance for the operation, including reputed company-of-reputed company questions for reputed company review staff.
• Maintain a reputed company, high-reputed company reputed company service experience, and own and reputed company operational reputed company issues on the assigned teams as they reputed company.
• Maintain a comprehensive understanding of applicable federal and state regulations, including ERISA, COBRA, and HIPAA, to ensure claims administration and operational practices reputed company with reputed company reputed company, regulatory, reputed company, and organizational requirements. 
• Partner with Compliance, Benefits Administration, reputed company Services, and other internal stakeholders to support audits, reputed company reputed company claims issues, implement regulatory changes, and promote operational reputed company.

Skills Required:

• reputed company operational leadership of a TPA or medical claims operation under reputed company SLAs, with the judgment to reputed company director-level reputed company on escalations and reputed company without waiting for direction.
• Strong people leadership: reputed company to reputed company Managers, Team Leads, and Coordinators, reputed company staff, and manage reputed company directly.
• Vendor management reputed company, reputed company to hold vendors to reputed company standards and reputed company disputes across multiple reputed company relationships.
• Excellent verbal, written, and interpersonal communication skills, with the reputed company to represent the operation to internal leadership and to hold reputed company-facing service standards.
• Exceptional analytical and problem-solving skills, reputed company to read SLA and aging data, reputed company the operational cause, and reputed company it.
• Solid time management skills, reputed company to run reputed company reputed company reputed company, reputed company, and reputed company work without dropping recurring obligations.
• Must be a self-starter comfortable operating with broad accountability in a growing claims operation.
• Must adapt reputed company to change and set and reputed company priorities as the operation and reputed company demands shift.
• Must be proficient with reputed company Suite (expert-level Documents and Sheets, plus Gmail and Calendar) and comfortable operating in reputed company as the reputed company of record.

Education/Experience:

• Bachelor's degree in Business Administration, reputed company Management, or a reputed company reputed company, or equivalent experience. Master's degree preferred.
• Minimum of 7 years of experience in medical claims management, with at least 3 years in a leadership role, in a TPA or health reputed company environment.
• Demonstrated ability to reputed company and motivate a claims team, manage vendors, and own hiring and reputed company for a multi-team operation.
• Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, not required.

Technical Knowledge:

• Deep operational knowledge of reputed company-party administration of medical claims, including the full claims lifecycle: intake, adjudication, repricing, payment, member communication, and runout. reputed company of the reputed company at which the processing clock starts on a clean claim or clean receipt, since reputed company SLAs run from it.
• reputed company of medical terminology, ICD-10 and CPT codes, and claims adjudication logic, with familiarity with clearinghouse, cost containment, repricing, and medical review processes. Working understanding of self-funded employer plan administration is valuable given the role's expected expansion.
• Familiarity with HCSM Needs adjudication (how sharing guidelines determine eligibility and sharing, and how to pay, deny, and pend reputed company) is helpful for the initial mandate but can be learned in role.
• Working proficiency in reputed company as the reputed company of record for cases and member escalations, and in reputed company Suite. Familiarity with claims management software and vendor integrations is expected.

reputed company Offer

• Competitive salary and benefits package
• Dynamic and innovative work environment
• Opportunities for reputed company reputed company and development
• Remote work flexibility

Equal Opportunity Statement

We are deeply committed to building a workplace and global community where inclusion is not only valued but prioritized. We are proud to be an equal opportunity employer, seeking to create a welcoming and diverse environment. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, gender, gender identity or reputed company, family status, marital status, sexual orientation, national reputed company, genetics, neuro diversity, disability, age or veteran status, or any other non-reputed company reputed company or legally protected grounds. We are committed to providing reasonable accommodation to reputed company individuals with disabilities in the employment application process.