Director Claims Management

Health Admins is a leading force in healthcare administration, evolving into a premier technology-driven healthcare platform. Our vision is anchored in a commitment to Getting Better Every Step of the Way. We provide innovative, efficient solutions that elevate the healthcare experience for the members and clients we serve.

About the role

The Director of Claims Management is the accountable operational leader for a third-party administrator (TPA) medical claims operation. This role manages a multi-team claims operation under client service level agreements (SLAs), owns delivery quality, and oversees the staff, vendors, and projects that ensure accurate and timely claims processing. The Director reports to the VP of Operations and may require occasional travel.

Responsibilities

• Own full accountability for the assigned claims operation, ensuring claims are processed accurately and within required timeframes. Develop strategies, staffing, and process improvements to maintain performance as volume grows.
• Manage the two health share Needs teams, including adjudication of member Needs across intake, clinical review, processing, pay/deny/pend determination, reimbursements, and runout.
• Meet and sustain each client's service level agreements, with current health share teams processing claims within 21 to 45 days or within 30 days of clean receipt. Track SLAs and respond when standards are at risk.
• Expand into traditional medical claims administration for self-funded employer plans, applying standard TPA claims practice across intake, adjudication, repricing, payment, and runout.
• Lead Client Managers, Team Leads, and Coordinators across assigned teams. Manage workload distribution, escalation handling, performance management, hiring, and staff development to foster a high-performance, continuous-improvement culture.
• Manage vendor relationships supporting the operation, including clearinghouse, cost containment, medical review, staffing, and related functions. Own vendor performance and resolve disputes.
• Own hiring and staffing plans, including filling approved headcount, building bench depth for key roles, and partnering on compensation benchmarking to maintain SLAs as volume shifts.
• Oversee active projects affecting the operation, such as system and reporting changes, vendor implementations, and go-lives, serving as the operational owner while project management drives execution.
• 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 up-to-date knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practices. Ensure operational compliance, including scope-of-practice for clinical review staff.
• Maintain a seamless, high-quality client service experience and resolve operational client issues as they arise.
• Ensure compliance with federal and state regulations, including ERISA, COBRA, and HIPAA, for claims administration and operational practices.
• Partner with Compliance, Benefits Administration, Client Services, and other internal stakeholders to support audits, resolve complex claims issues, implement regulatory changes, and promote operational excellence.

Requirements

• Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience. Master's degree preferred.
• Minimum of 7 years of experience in medical claims management, with at least 3 years in a leadership role within 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.
• Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus.

Skills

• Proven operational leadership of a TPA or medical claims operation under client SLAs, with the ability to make director-level decisions on escalations and staffing.
• Strong people leadership skills, including the ability to lead Managers, Team Leads, and Coordinators, develop staff, and manage performance.
• Vendor management expertise, with the ability to hold vendors to performance standards and resolve disputes across multiple relationships.
• Excellent verbal, written, and interpersonal communication skills, with the presence to represent the operation to internal leadership and clients.
• Exceptional analytical and problem-solving skills, with the ability to interpret SLA and aging data, identify operational causes, and take action.
• Solid time management skills to handle concurrent client operations, projects, and staffing without neglecting recurring obligations.
• Self-starter comfortable operating with broad accountability in a growing claims operation.
• Adaptability to change and the ability to set and adjust priorities as the operation and client demands shift.
• Proficiency with Google Suite (expert-level in Documents and Sheets, plus Gmail and Calendar) and comfort operating in Salesforce as the system of record.

Technical Knowledge

• Deep operational knowledge of third-party administration of medical claims, including the full claims lifecycle: intake, adjudication, repricing, payment, member communication, and runout.
• Understanding of the point at which the processing clock starts on a clean claim or clean receipt, as client SLAs are tied to this.
• Command of medical terminology, ICD-10 and CPT codes, and claims adjudication logic. Familiarity with clearinghouse, cost containment, repricing, and medical review processes.
• Working understanding of self-funded employer plan administration, valuable for the role's expected expansion.
• Familiarity with HCSM Needs adjudication (how sharing guidelines determine eligibility and sharing, and how to pay, deny, and pend outcomes) is helpful but can be learned on the job.
• Working proficiency in Salesforce as the system of record for cases and member escalations, and in Google Suite.
• Familiarity with claims management software and vendor integrations.

Benefits

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