Director, Claims Administration

The Director, Claims Administration governs enterprise outcomes and risk controls, introducing a preventative orientation and regulatory accountability. This position is responsible for leading the end-to-end claims ecosystem, including claims adjudication, claims adjustments, and strong focus on preventative controls through the Service Validation Unit (SVU).

Requirements

• At least 7 years of healthcare claims (Medicare, Medicaid, and Commercial) experience.
• At least 5 years of experience leading, supervising and/or managing staff.
• Experience in Medicaid, Medicare, and Commercial managed care lines of business.
• Demonstrated experience leading claims adjudication, adjustments, disputes, escalations, and related functions.
• Extensive experience interpreting provider contracts, payment methodologies, and managed care benefit structures
• Experience handling complex claim review, root-cause evaluation, adhering to regulatory timeliness requirements, and ensuring accuracy.
• Significant experience administering quality review programs and implementing sustainable operational improvements.
• Experience supporting litigation, state or federal inquiries, and regulatory audits.
• Demonstrated experience with high complexity claims review and RCA.

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)