• Provide leadership and oversight for the intake, investigation, prioritization, and resolution of complex claims issues impacting payment accuracy, provider experience, and operational performance.
• Direct root cause analysis efforts, leveraging cross-functional subject matter experts to identify systemic issues and implement sustainable corrective actions.
• Establish and maintain monitoring, tracking, and reporting processes to identify claims payment and denial trends, risks, and improvement opportunities.
• Assist with financial impact assessments and remediation strategies, including identification and correction of affected claims when necessary.
• Partner with internal stakeholders to ensure timely issue resolution, alignment of priorities, and accountability for corrective action implementation.
• Build, develop, and mentor a high-performing team while fostering a culture of accountability, collaboration, innovation, and continuous improvement.
• Directs the daily operations of the provider call center to ensure consistent adherence to service level agreements (SLAs), CMS compliance regulations, and state mandates.

QUALIFICATIONS

Education - Required

• High School Diploma/GED

Experience - Required

• 7 years progressive experience in insurance claims administration, medical billing, or denials and appeals management and
• 5 years experience in a supervisory or departmental management capacity, demonstrating the ability to lead large teams of analysts.

Knowledge, Skills and Abilities - Required

• Deep operational experience handling complex disputes, complex contract terms, and medical coding reconsiderations
• The ability to look past individual claim errors to identify systemic flaws in data feeds, provider billing habits, or internal auto-adjudication systems.