Director of Claims Administration
Posted 2025-04-06ONLY eligible if located in the following states or open to relocation: Oregon, Washington, Arizona, Mississippi or North Carolina.
Role Overview:
The Director of Claims Administration reports to the Chief Performance Officer and is responsible for oversight and management of all aspects of the Claims Administration Department to ensure operations are efficient, progressive, effective, and compliant with state/federal regulations as well as applicable company policies and procedures. Responsible for ensuring contractual obligations are met, regulatory timeframes are adhered to, and customers are provided with a high level of service. Must meet or exceed performance standards
Role Responsibilities:
1. Department Management: Responsible for management and oversight of the Claims Administration Department to include the following Â
1.1. Coordination of staff and department workflows to ensure all activities are handled and completed in a timely, productive, accurate, efficient, team oriented, and pro-active manner.
1.2. Responsible for developing, evaluating, and revising claims administration (e.g. claims, customer service, and eligibility) policies, procedures, manuals, and reference materials appropriately to effectively support performance excellence as well as align with state, federal, and client requirements.
1.3. Maintains quality service by enforcing quality and customer service standards, analyzing, and resolving quality and customer service problems, and recommending system improvements.
1.4. Defines objectives, identifies, and evaluates trends and options, chooses a course of action, and evaluates outcomes. Ongoing focus on strategic growth, scalability, CQI, automation, process improvements, compliance, and customer needs.
1.5. Key risks are identified, monitored, and mitigated.
1.6. Manages compliance with Federal/Medicare and State regulations and delegated entity requirements as they relate to Claims Administration.
1.7. Manages mid to high level and sensitive complaints and/or issues to ensure they are resolved appropriately and timely as well as within CHP standards and policies.
1.8. Manages key client and other relationships.
1.9. Assists with departmental budget development and implementation.
1.10. Ensures the efficiency, progression, and accuracy of the software programs (e.g. QNXT, SharePoint) utilized by the Claims Administration Department.
1.11. Initiates and maintains effective channels of communication with other CHP departments, including but not limited to, Provider Relations, Credential Stream, Information Technology, Clinical Services, Finance, Human Resources, and Sales and Marketing.
2. Staff Management - Recruit, train, develop, mentor, coach, supervise, and evaluate direct reports. Ensure performance expectations and standards are conveyed and clearly understood by department staff. Ensure staff achieve all department/company goals as well as adherence to department/company policies and procedures. Evaluate employeeÂs performance by conducting annual performance reviews and periodic performance check-in meetings. Ensure that staff have the information, tools, and resources necessary to perform their jobs.
2.1. Cross-Training Staff to enhance the growth of CHP as it relates to new business and/or staff development.
3. Demonstrate Leadership by promoting a positive, team oriented, customer service driven, and productive work environment. Exhibit strong leadership qualities and proactively work to build and improve the team and department. Provide leadership to ensure staff have an ongoing understanding of the strategic and operational direction of the department and company.
4. Regulatory and Compliance: Proactively monitor and ensure that the claims administration department operates in compliance with applicable state, federal and HIPAA requirements as well as meeting client service agreements.
5. Customer Service - Ensure exemplary customer service is provided to members, providers, employer groups, health plans, and internal staff while adhering to customer service guidelines and meeting quality standards. Position requires a customer-orientation and commitment to enhancing customers experience. Must maintain professional etiquette during all interactions with customers and emotional management skills. Assist with answering phones on an on needed basis.:
5.1. Members: Serve as customer service contact and address questions and issues including, but not limited to: eligibility, benefits, claims processing, provider responsibilities, grievances, finding network providers, and plan navigation.
5.2. Providers: Serve as customer service contact and address claims administration questions and/or issues including, but not limited to, member eligibility, benefits, claims processing, provider responsibilities, and grievances.
5.3. Health Plans: Serve as customer service contact and address claims administration questions or issues including, but not limited to, claims processing, eligibility, and provider/member grievances (coordinate with other departments managing complaint processes).
6. Claims Processing  Assist with processing claims, on an as needed basis, in a productive, efficient, timely and accurate manner in accordance with internal policies.
7. Performance Metrics: Responsible for achieving established performance metrics, as indicated by supervisor, including department and company/client key performance indicators, ensuring staff meet performance expectations and accuracy/production standards. CQI/process improvement initiatives, root cause/trend analysis
Other Functions
 Attend organization management meetings
 Lead and facilitate Claims Administration Department meetings
 Attend All-Staff meetings
 Assist with special projects and initiatives as needed
 Other functions and duties as assigned
Interpersonal and Communication Skills
 Must effectively promote a positive image of the company to employees, customers, and the general public.
 Must be able to communicate well both verbally and in writing with all levels of personnel and management in an environment with multiple work demands, including external contacts.
 Must have strong organizational skills and be able to work independently with limited supervision.
 Must be able to examine complex information and/or situations, evaluate the potential impact, identify options, and make recommendations.
 Must have the ability to establish and maintain effective working relationships.
 Must be able to work in a team environment and produce results in conjunction with fellow team members.
Minimum Qualifications and Experience
 BachelorÂs degree required
 8+ years experience as a health plan/carrier claims or customer service Director or equivalent claims and customer service experience, and ability to take initiative and work independently as appropriate
 Knowledge of state, federal, and other regulations as it relates to claims and customer service administration
 In-depth knowledge of claim adjudication principles and procedures
 Knowledge of medical and health insurance terminology including CPT, HCPCS, and ICD-10 coding
 Prior experience with Medicare and Medicaid programs preferred
 Experience with QNXT Claims Processing system preferred
Apply Job!