Job Description

The Director of Claims oversees all delegated claims operations to ensure accuracy, compliance, and efficiency. This role plays a key part in reviewing departmental reports for data integrity, driving productivity, and collaborating with internal teams to ensure timely and accurate reporting to health plans. The Director works closely with the Claims Manager and VP of Finance to support audits, improve quality outcomes, create dashboards, and contribute to the financial and operational success of the organization.

Essential Duties & Responsibilities

• Lead the Claims Department to ensure compliance with Medicare Advantage, managed care delegation, and regulatory requirements.
• Define and execute strategic goals to enhance claims accuracy, timeliness, and efficiency.
• Manage, develop, and evaluate staff performance, including coaching and training.
• Develop and maintain departmental policies, procedures, and productivity standards.
• Monitor key performance metrics, identify trends, and implement corrective actions.
• Prepare for and support internal and external audits by ensuring proper documentation and data integrity.
• Collaborate cross-functionally with Contracting, Clinical, Finance, and IT departments to align processes and reporting.
• Communicate with internal and external partners, including payers and delegated entities, to resolve issues and ensure compliance.
• Stay current on regulatory and payer policy changes impacting claims processing.
• Participate in budgeting, resource planning, and continuous process improvement initiatives.
• Foster a culture of accountability, collaboration, and continuous learning.

Qualifications

• 10+ years of healthcare claims or revenue cycle management experience, with 5+ years in a managerial role.
• Strong analytical, problem-solving, and data interpretation skills.
• Proven ability to lead teams and drive operational performance improvements.
• Excellent communication, interpersonal, and leadership abilities.
• Knowledge of Medicare, commercial insurance billing, and payer compliance regulations.
• Experience with delegated claims operations and audits preferred.
• Proficiency in claims systems (e.g., EZCap, EZEDI) and Microsoft Excel; EMR software experience required.

Education

• Bachelor’s degree in a related field preferred.
• Equivalent experience (10+ years) accepted in lieu of degree.

Knowledge, Skills & Abilities

• Advanced understanding of healthcare billing and reimbursement processes.
• Intermediate to advanced proficiency in Microsoft Office Suite.
• Strong attention to detail and ability to maintain confidentiality.
• Excellent organizational and time management skills.