Director of Claims

About the Role

The Director of Claims is responsible for overseeing and directing delegated claims operations to ensure accuracy, compliance, and efficiency. This role involves reviewing departmental reports to ensure the integrity of claims data and collaborating with other departments to support accurate and timely reporting to health plans. The Director works independently to identify improvement opportunities, develop job aides, and drive productivity, partnering closely with the Claims Manager and VP of Finance to support audits, strengthen quality outcomes, and contribute to the financial and operational success of HealthTexas while upholding our Mission, Vision, and Values.

Culture and Values Expectations

At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered, and motivated to reach their full potential. Our culture drives our mission to deliver quality and compassionate care with outstanding service, every patient, every time. As a Director of Claims, you are expected to embody and promote our Values and defined behavioral expectations:

• Integrity: Do the right thing, the right way, every time. Be honest, uphold commitments, earn trust, and maintain confidentiality.
• Compassion: Treat everyone with respect and dignity. Foster inclusivity, practice empathy, and assume positive intent.
• Synergy: Collaborate to improve outcomes. Promote effective communication, teamwork, and pride in your work and HealthTexas.
• Stewardship: Use resources responsibly. Implement strategies to achieve goals, maximize productivity, and seek continuous improvement.

Responsibilities

• Lead the Claims department, ensuring compliance with Medicare Advantage, managed care delegation, company policies, and regulatory requirements.
• Define and execute strategic goals to enhance claims accuracy, timeliness, efficiency, and alignment with organizational objectives.
• Manage, develop, and evaluate staff: set expectations, conduct performance reviews, coach, and address performance issues.
• Establish, maintain, and update policies, procedures, and productivity standards guiding departmental operations.
• Monitor key metrics (e.g., claim accuracy, processing speed, audit findings), identify trends, and implement corrective actions.
• Prepare for audits by maintaining documentation, responding to findings, and ensuring data integrity.
• Collaborate with Contracting, Clinical, Finance, IT, and other stakeholders to integrate processes, reporting, and system changes.
• Communicate with internal and external partners to resolve issues, support compliance, and ensure service quality.
• Stay current with regulatory/payer/delegation changes and incorporate them into practices.
• Participate in budget/resource planning, process improvement initiatives, and cross-departmental activities.
• Foster a culture of accountability, continuous learning, and collaboration within the department.
• Perform other duties as assigned.

Requirements

• 10 years in healthcare claims or revenue cycle management, with at least 5 years of managerial experience.
• Strong analytical and problem-solving skills, with the ability to independently learn and apply new concepts.
• Ability to review, interpret, and validate complex reports and data sets.
• Excellent communication and interpersonal skills, with a focus on collaboration and team development.
• Knowledge of Medicare guidelines and healthcare claims regulations.
• Familiarity with delegated claims audits and payer compliance requirements preferred.
• Proficiency in claims systems (e.g., EZCap, EZEDI) and Microsoft Excel; EMR software experience required.

Qualifications

• Bachelor’s Degree in a related field preferred; 10+ years of relevant experience may substitute for degree.
• Proficiency with computers, Microsoft Excel, and Office products.
• Extensive knowledge of billing regulations for Medicare, commercial, HMO, and PPO plans.
• Understanding of patient privacy and confidentiality.

Schedule

Monday – Friday, 8:00 a.m. – 5:00 p.m., with flexibility to complete projects. Travel to medical offices may be required for benefit education.

Working Conditions & Physical Requirements

This role operates in an office setting, using standard office equipment. It is largely sedentary but requires occasional filing, lifting, bending, and standing. Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and focus adjustment.