Role: Director of Claims Operations (Group Leader)

Location: Tampa, FL (Hybrid)

Summary:

The Director of Claims Operations and Service Delivery is responsible for the overall strategy and effectiveness of Claims Operations. This role oversees claims adjudication, regulatory reporting functions, and all associated processes. The Director ensures timely and accurate claims processing, manages vendor relationships, and identifies opportunities for operational efficiencies. This position also involves hiring, training, and performance management of the Claims staff.

Education and Experience:

• Bachelor’s Degree in business, healthcare administration, or a related field (Master’s preferred).
• Minimum 7-10 years of claims and healthcare administration and/or managed care management experience.
• Strong knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, DSNP, ACA, etc.).
• Extensive knowledge of claims policies and procedures, including regulatory requirements and industry standards from AMA, CMS, and CCI edits.
• Experience managing geographically dispersed (onshore and offshore), hybrid, remote, onsite teams.
• Experience managing multinational operations is preferred.

Essential Duties and Responsibilities:

Strategic Leadership:

• Provide strategic direction for the claims department, aligning operations with company goals and regulatory requirements.
• Lead, mentor, and develop a high-performing claims management team.
• Collaborate with executive leadership to establish and achieve claims-related KPIs and financial targets.
• Identify and implement solutions for operational weaknesses.

Claims Management Operations:

• Oversee end-to-end claims operations, including processing, adjudication, and resolution.
• Develop and implement policies, procedures, and workflows to optimize efficiency and mitigate errors.
• Monitor and address claim denial trends, providing actionable insights and corrective strategies.
• Manage relationships with payers, vendors, and other key stakeholders.

Compliance and Reporting:

• Ensure compliance with state, federal, and industry regulations, including HIPAA and CMS guidelines.
• Prepare and present regular reports on claims performance, trends, and department metrics.
• Conduct audits and reviews to maintain high standards of accuracy and compliance.

Team Development:

• Provide leadership and coaching to the Claims staff, fostering a culture of accountability and professional development.
• Develop staffing models to support the Claims budget process.
• Implement a comprehensive Claims Quality program to measure financial and clerical accuracy.

Operational Efficiency:

• Utilize a detailed understanding of insurance processes and business systems to drive research and analysis.
• Develop and maintain departmental policies, procedures, and desktop procedures according to current business needs and regulatory requirements.
• Monitor system and business functionality and performance.