Job Description

Position Summary:

The Director of Claims Operations is responsible for overseeing all functions of the Claims department, ensuring compliance with Medicare Advantage, managed care delegation, and regulatory requirements. This leadership role focuses on driving accuracy, timeliness, and operational efficiency while fostering collaboration across departments and maintaining strong relationships with internal and external partners.

Essential Duties and Responsibilities:

• Lead and manage the Claims department, ensuring all activities comply with organizational policies, payer requirements, and regulatory standards.
• Develop and execute strategic goals to improve claims accuracy, processing efficiency, and departmental performance.
• Supervise, mentor, and evaluate staff performance; provide coaching, feedback, and professional development opportunities.
• Establish and maintain policies, procedures, and productivity standards to guide daily operations.
• Monitor key performance metrics such as claims accuracy, turnaround time, and audit results; identify issues and implement corrective measures.
• Prepare for and support audits by maintaining documentation, ensuring data integrity, and responding to findings promptly.
• Collaborate with departments such as Contracting, Clinical, Finance, and IT to align processes and system updates.
• Communicate effectively with providers, delegated entities, and payers to resolve issues and ensure service excellence.
• Stay current with regulatory and payer updates, incorporating new requirements into department practices.
• Participate in budget planning, resource allocation, and process improvement initiatives.
• Foster a culture of accountability, teamwork, and continuous learning within the department.
• Perform other related duties as assigned.

Qualifications & Experience:

• Minimum of 10 years of experience in healthcare claims or revenue cycle management, including at least 5 years in a leadership or managerial role.
• Strong understanding of Medicare and managed care regulations, including Medicare Advantage guidelines.
• Experience with delegated claims operations, audits, and payer compliance.
• Demonstrated analytical and problem-solving skills with the ability to interpret and validate complex data sets and reports.
• Excellent communication, leadership, and interpersonal skills with a focus on collaboration and team development.
• Proficiency in claims systems such as EZCap, EZEDI, or similar platforms, and advanced knowledge of Microsoft Excel.
• Experience with electronic medical record (EMR) software is required.

Education:

• Bachelor’s Degree in Business, Healthcare Administration, or a related field preferred.
• In lieu of degree, a minimum of 10 years of relevant experience will be considered.

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