Director, Claims Support
Job Description Summary
The Director, Claims Support is responsible for the strategic and operational leadership of CareMore Health's claims administration function, ensuring the accurate, timely, and compliant adjudication and payment of medical, behavioral health, pharmacy, and ancillary claims. This role oversees claims operations across multiple markets and systems, drives operational excellence, and ensures compliance with Medicare, Medicaid, Commercial, CMS, and state regulatory requirements.
The Director develops and executes claims strategies that support organizational objectives, provider satisfaction, member experience, payment integrity, and financial stewardship. Serving as a key leader within Health Plan Operations, the Director partners closely with Provider Network Management, Finance, Compliance, Configuration, Delegation Oversight, Appeals & Grievances, Clinical Operations, and external provider organizations to ensure optimal claims performance and regulatory compliance.
How will you make an impact & Requirements
Hours & Location:
Full Time: Monday-Friday, Pacific Time
Remote work
Essential Responsibilities
Direct all aspects of claims intake, adjudication, payment, adjustment, and provider reimbursement activities.
Ensure claims are processed accurately, timely, and in compliance with contractual, regulatory, and organizational requirements.
Provide leadership and guidance on highly complex claims and provider disputes.
Establish and monitor operational metrics, SLAs, productivity standards, and quality indicators.
Lead continuous improvement initiatives focused on automation, efficiency, payment accuracy, and provider experience.
Ensure compliance with CMS, Medicare Advantage, Medicaid, and state regulations.
Lead strategic planning, budgeting, workforce planning, and operational transformation initiatives.
Partner with providers, delegated entities, vendors, and internal stakeholders to resolve issues and improve performance.
Lead, coach, and develop managers and claims professionals across multiple locations.
Required Qualifications
Bachelor's degree in Business Administration, Healthcare Administration, Finance, Public Health, or related field, or equivalent experience.
Minimum 9 years of progressive healthcare claims operations experience.
Minimum 5 years of leadership experience managing managers and/or large operational teams.
Experience within Medicare Advantage, Medicaid, Managed Care, Health Plan, or Payer environments.
Preferred Qualifications
Master's degree (MBA, MHA, MPH, or related field).
Experience supporting delegated provider organizations, value-based care models, payment integrity programs, and provider dispute resolution.
Benefits:
3 weeks PTO & 8 paid holidays
Medical, Dental, Vision
Employer Paid Basic Life & Short Term Disability coverage (goes into effect after 1 year of full-time employment)
401(k) with match
Employee Wellness
Other Employee Discount programs like Tickets at Work and cell phone discounts
Other benefits: Dependent Care FSA, Voluntary Life, Long Term Disability, Critical Illness, Pet Insurance, and more
Compensation:
$144,368.00to
$238,207.00
The Director, Claims Support is responsible for the strategic and operational leadership of CareMore Health's claims administration function, ensuring the accurate, timely, and compliant adjudication and payment of medical, behavioral health, pharmacy, and ancillary claims. This role oversees claims operations across multiple markets and systems, drives operational excellence, and ensures compliance with Medicare, Medicaid, Commercial, CMS, and state regulatory requirements.
The Director develops and executes claims strategies that support organizational objectives, provider satisfaction, member experience, payment integrity, and financial stewardship. Serving as a key leader within Health Plan Operations, the Director partners closely with Provider Network Management, Finance, Compliance, Configuration, Delegation Oversight, Appeals & Grievances, Clinical Operations, and external provider organizations to ensure optimal claims performance and regulatory compliance.
How will you make an impact & Requirements
Hours & Location:
Full Time: Monday-Friday, Pacific Time
Remote work
Essential Responsibilities
Direct all aspects of claims intake, adjudication, payment, adjustment, and provider reimbursement activities.
Ensure claims are processed accurately, timely, and in compliance with contractual, regulatory, and organizational requirements.
Provide leadership and guidance on highly complex claims and provider disputes.
Establish and monitor operational metrics, SLAs, productivity standards, and quality indicators.
Lead continuous improvement initiatives focused on automation, efficiency, payment accuracy, and provider experience.
Ensure compliance with CMS, Medicare Advantage, Medicaid, and state regulations.
Lead strategic planning, budgeting, workforce planning, and operational transformation initiatives.
Partner with providers, delegated entities, vendors, and internal stakeholders to resolve issues and improve performance.
Lead, coach, and develop managers and claims professionals across multiple locations.
Required Qualifications
Bachelor's degree in Business Administration, Healthcare Administration, Finance, Public Health, or related field, or equivalent experience.
Minimum 9 years of progressive healthcare claims operations experience.
Minimum 5 years of leadership experience managing managers and/or large operational teams.
Experience within Medicare Advantage, Medicaid, Managed Care, Health Plan, or Payer environments.
Preferred Qualifications
Master's degree (MBA, MHA, MPH, or related field).
Experience supporting delegated provider organizations, value-based care models, payment integrity programs, and provider dispute resolution.
Benefits:
3 weeks PTO & 8 paid holidays
Medical, Dental, Vision
Employer Paid Basic Life & Short Term Disability coverage (goes into effect after 1 year of full-time employment)
401(k) with match
Employee Wellness
Other Employee Discount programs like Tickets at Work and cell phone discounts
Other benefits: Dependent Care FSA, Voluntary Life, Long Term Disability, Critical Illness, Pet Insurance, and more
Compensation:
$144,368.00to
$238,207.00