Claims Operations Director at Capital Health Plan in Tallahassee, FL, USA

Job description

• We are seeking a Claims Operations Director to lead and oversee Capital Health Plan's end‑to‑end claims operations, including claims processing, other party liability (OPL) recoveries, premium billing and reconciliation, contract administration, and payment integrity functions.
• This role directs multiple operational teams and managers, ensuring the timely, accurate, and compliant processing of claims and premiums while maintaining the integrity of provider records, contract configurations, and reimbursement systems. The Claims Operations Director partners closely with senior leadership, cross‑functional teams, and third‑party vendors to drive operational performance, regulatory compliance, system enhancements, and continuous improvement across all claims‑related functions.

Responsibilities

• Lead and oversee end-to-end claims operations, including claims processing, other party liability (OPL) recoveries, premium billing and reconciliation, contract administration, and payment integrity functions
• Direct multiple operational teams and managers, ensuring timely, accurate, and compliant processing of claims and premiums
• Maintain integrity of provider records, contract configurations, and reimbursement systems
• Partner closely with senior leadership, cross-functional teams, and third-party vendors to drive operational performance, regulatory compliance, system enhancements, and continuous improvement

Requirements

• Bachelor's degree from an accredited four-year college or university, or equivalent education and experience
• Significant leadership experience in claims operations, healthcare administration, or related functions; ten years of related experience preferred
• Demonstrated experience managing multi-disciplinary operational teams within a healthcare or payer environment
• Strong working knowledge of claims administration, premium billing, contract configuration, and payment integrity processes
• Ability to develop workflows, productivity standards, and performance metrics to meet operational and regulatory goals
• Strong analytical skills with experience using data to set KPIs and support senior leadership reporting
• Thorough understanding of healthcare billing and coding concepts (e.g., CPT, ICD, revenue codes)
• Strong written and verbal communication skills, including the ability to present complex operational information to senior leadership
• Experience overseeing Medicare reimbursement processes and adapting to regulatory changes
• Experience with provider contract administration and system configuration management
• Experience managing software enhancements, reimbursement systems, or claims adjudication platforms
• Familiarity with provider billing operations and dispute resolution processes
• Strong financial acumen, including basic accounting knowledge and reconciliation concepts
• Experience leading cross-functional initiatives to improve claims, billing, or payment integrity outcomes

Skills

Required

• Leadership
• Claims operations
• Healthcare administration
• Claims administration
• Premium billing
• Contract configuration
• Payment integrity
• Workflow development
• Productivity standards
• Performance metrics
• Analytical skills
• Data analysis

Preferred

• Medicare reimbursement
• Regulatory adaptation
• Provider contract administration
• System configuration management
• Software enhancements
• Reimbursement systems
• Claims adjudication platforms
• Provider billing operations