Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or related field; Master's preferred.
8+ years of progressive health plan claims operations experience.
7+ years of leadership experience managing managers and senior leaders.
Experience with Medicare, Medicaid, Commercial, Marketplace, and Special Needs products.
Proven track record in leading regulatory audits and operational transformation initiatives.
Extensive knowledge of managed care claims administration and claims systems.
Strong understanding of CMS and New York regulatory requirements.
Responsibilities
Serve as second-in-command to the Vice President of Claims.
Direct all medical, behavioral health, and BPaaS claims operations.
Ensure timely and compliant adjudication of claims across all product lines.
Establish departmental goals, policies, and performance expectations.
Lead initiatives to improve auto-adjudication rates and operational efficiency.
Develop and execute strategic plans for the Claims organization.
Monitor vendor performance against contractual service-level agreements.
Benefits
Promote a culture of accountability and continuous improvement.
Opportunity for leadership development and succession planning.
Engagement in enterprise-wide projects and system modernization.
Access to executive-level reporting and operational analysis.
Collaboration with executive leadership on growth initiatives.
Full Job Description
Position Overview The Senior Director of Claims provides strategic and operational leadership for the Claims Department and serves as the primary deputy to the Vice President of Claims. This role directs claims administration, processing, configuration testing, quality assurance, auditing, provider reimbursement accuracy, delegated vendor oversight, performance management, and regulatory compliance. The position is accountable for the daily execution of claims operations and partners with executive leadership to develop and implement long-term strategies supporting organizational goals, member and provider satisfaction, operational excellence, regulatory compliance, and financial stewardship. The incumbent serves as acting leader of the Claims Department in the absence of the Vice President of Claims.
Scope of Role & Responsibilities
Serve as second-in-command to the Vice President of Claims and act on behalf of the Vice President when designated.
Direct all medical, behavioral health, and delegated Business Process as a Service (BPaaS) claims operations.
Ensure timely, accurate, and compliant adjudication of claims across all product lines.
Ensure timely, accurate, and compliant research, review, and processing of post-processing adjustments, inquiries, and complaints.
Establish departmental goals, policies, procedures, and performance expectations.
Oversee inventory management, productivity, turnaround time, quality, and financial accuracy metrics.
Lead initiatives to improve auto-adjudication rates, payment accuracy, and operational efficiency.
Provide executive-level reporting, operational analysis, and recommendations to senior leadership.
Lead enterprise-wide projects involving claims operations, automation, and system modernization.
Develop and execute short- and long-term strategic plans for the Claims organization.
Identify operational improvement opportunities and implement scalable solutions.
Partner with executive leadership on growth initiatives, product implementations, and organizational priorities.
Evaluate industry trends, emerging technologies, and best practices affecting claims administration.
Sponsor major systems implementations, workflow redesign, and transformation efforts.
Ensure compliance with CMS, federal, New York State Department of Health, Department of Financial Services, and accreditation requirements.
Lead preparations for regulatory audits, validations, and corrective action plans.
Monitor prompt-pay compliance, claims accuracy standards, and contractual obligations.
Maintain policies and procedures that support regulatory compliance.
Provide executive oversight of delegated entities and business partners.
Monitor vendor performance against contractual service-level agreements.
Conduct operational reviews and implement corrective actions when necessary.
Ensure delegated activities comply with organizational and regulatory requirements.
Lead, coach, and develop Directors, Associate Directors, Managers, and Supervisors.
Create succession plans for key leadership positions.
Oversee recruitment, onboarding, performance management, and leadership development.
Promote a culture of accountability, collaboration, and continuous improvement.
Maintain and enhance executive dashboards and operational scorecards.
Analyze operational trends and implement performance improvement initiatives.
Present operational results and strategic recommendations to executive leadership.
Required Education, Training & Professional Experience
Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or a related field required; Master's degree in Business Administration, Health Administration, Public Health, or a related discipline preferred.
Eight or more years of progressive health plan claims operations experience.
Seven or more years of leadership experience managing managers and senior leaders.
Experience with Medicare, Medicaid, Commercial, Marketplace, and Special Needs products.
Experience leading regulatory audits, operational transformation initiatives, and large-scale teams.
Extensive knowledge of managed care claims administration and claims systems.
Strong understanding of CMS and New York regulatory requirements.
Required Licensure and/or Certification
No specific professional licensure or certification is required.
Professional Competencies
Integrity and Trust
Customer Focus
Functional/Technical Skills
Strategic Thinking
Executive Presence
Business Acumen
Operational Excellence
Change Leadership
Talent Development
Relationship Management
Results Orientation
Innovation
Accountability
Excellent analytical, financial, problem-solving, and decision-making skills.
Exceptional executive communication and presentation abilities.
Ability to influence cross-functional stakeholders and drive change.
