Director, Claims Management

🔥 1 minute ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🔴 Lead

👔 Director

👻 Ghost score 10%

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Health Admins

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2015

💼 Consulting

🛡️ Insurance

📣 Marketing

Consulting • Insurance • Marketing

Health Admins is leading healthcare in a new direction by simplifying access to healthcare services and making them more affordable for members. Through their Smart Healthcare Platform, they provide TPA software, healthcare navigation, bill negotiation, and claims processing services. Their goal is to enhance member satisfaction and foster loyalty by offering powerful tools and personalized assistance to control costs and improve healthcare decisions.

📋 Description

• Lead the assigned third-party administrator medical claims operation under client service level agreements • Ensure claims are processed accurately and within required timeframes • Run the two health share Needs teams, including intake, clinical review, processing, pay/deny/pend determinations, reimbursements, and runout • Meet and sustain client SLAs, including processing timelines of roughly 21 to 45 days or within 30 days of clean receipt • Own SLA tracking and responses when standards are at risk • Build toward traditional medical claims administration for self-funded employer plans • Lead Client Managers, Team Leads, and Coordinators across assigned teams • Own workload distribution, escalations, performance management, hiring, and staff development • Manage vendor relationships across clearinghouse, cost containment, medical review, staffing, and related functions • Oversee vendor performance and resolve disputes and issues • Develop hiring and staffing plans, fill approved headcount, and build bench depth • Oversee operational projects, including system and reporting changes, vendor implementations, and go-lives • Analyze claims data to identify trends, issues, and opportunities and implement data-driven improvements • Prepare and present operational and performance reporting to senior leadership • Maintain compliance with healthcare regulations, including ERISA, COBRA, HIPAA, and scope-of-practice requirements • Maintain high-quality client service and resolve operational client issues • Partner with Compliance, Benefits Administration, Client Services, and other internal stakeholders on audits, complex claims issues, regulatory changes, and operational excellence • Report to the VP of Operations • Travel occasionally as required

🎯 Requirements

• Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience • Minimum of 7 years of experience in medical claims management • At least 3 years in a leadership role in a TPA or health insurance environment • Demonstrated ability to lead and motivate a claims team, manage vendors, and own hiring and staffing for a multi-team operation • Proven operational leadership of a TPA or medical claims operation under client SLAs • Strong people leadership of Managers, Team Leads, and Coordinators • Vendor management skills • Excellent verbal, written, and interpersonal communication skills • Exceptional analytical and problem-solving skills • Solid time management skills • Must be a self-starter comfortable operating with broad accountability • Must adapt well to change and shifting priorities • Proficiency with Google Suite, including expert-level Documents and Sheets, Gmail, and Calendar • Comfortable operating in Salesforce as the system of record • Deep operational knowledge of third-party administration of medical claims and the full claims lifecycle • Knowledge of medical terminology, ICD-10 and CPT codes, and claims adjudication logic • Familiarity with clearinghouse, cost containment, repricing, medical review processes, claims management software, and vendor integrations • Working understanding of self-funded employer plan administration • Familiarity with HCSM Needs adjudication is helpful • Ability to maintain knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practices • Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, not required

🏖️ Benefits

• Competitive salary and benefits package • Opportunities for professional growth and development • Remote work flexibility