Expertise in claims administration and payment integrity
Skilled in workflow development and performance metrics
Strong analytical abilities for KPI setting
Knowledge of healthcare billing and coding (CPT, ICD)
Responsibilities
Direct end-to-end claims processing operations
Ensure compliance in claims and premium processing
Maintain integrity of provider records and contracts
Collaborate with senior leadership and cross-functional teams
Manage relationships with third-party vendors
Drive operational performance and regulatory compliance
Lead continuous improvement initiatives in claims functions
Benefits
Professional development opportunities
Collaborative work environment
Leadership support for operational innovation
Flexible work schedule as required
Full Job Description
Location: Tallahassee, FL
Department: Claims
FLSA: Exempt
Schedule: As required
About the role:
We are seeking a Claims Operations Director to lead and oversee Capital Health Plan's end-to-end claims operations, including claims processing, other party liability (OPL) recoveries, premium billing and reconciliation, contract administration, and payment integrity functions.
This role directs multiple operational teams and managers, ensuring the timely, accurate, and compliant processing of claims and premiums while maintaining the integrity of provider records, contract configurations, and reimbursement systems. The Claims Operations Director partners closely with senior leadership, cross-functional teams, and third-party vendors to drive operational performance, regulatory compliance, system enhancements, and continuous improvement across all claims-related functions.
We're looking for someone who has:
Bachelor's degree from an accredited four-year college or university, or equivalent education and experience
Significant leadership experience in claims operations, healthcare administration, or related functions; ten years of related experience preferred
Demonstrated experience managing multi-disciplinary operational teams within a healthcare or payer environment
Strong working knowledge of claims administration, premium billing, contract configuration, and payment integrity processes
Ability to develop workflows, productivity standards, and performance metrics to meet operational and regulatory goals
Strong analytical skills with experience using data to set KPIs and support senior leadership reporting
Thorough understanding of healthcare billing and coding concepts (e.g., CPT, ICD, revenue codes)
Strong written and verbal communication skills, including the ability to present complex operational information to senior leadership
Highly preferred candidates also have:
Experience overseeing Medicare reimbursement processes and adapting to regulatory changes
Experience with provider contract administration and system configuration management
Experience managing software enhancements, reimbursement systems, or claims adjudication platforms
Familiarity with provider billing operations and dispute resolution processes
Strong financial acumen, including basic accounting knowledge and reconciliation concepts
Experience leading cross-functional initiatives to improve claims, billing, or payment integrity outcomes
