Senior Director of Claims

Role: Senior Director of Claims (Service Delivery Leader)

Location: Tampa, FL (Hybrid)

Summary:

The Sr. Director of Claims is responsible for overseeing the entire claims function, including operations, contact center, provider and benefits configuration, and all other claims-related functions. This role ensures the efficient and effective management of claims processes, driving operational excellence and compliance. The Senior Director will report to the Head of Operations (COO) and will play a critical role in supporting the organization's strategic goals.

Education and Experience:

• Bachelor’s Degree in Business Administration, Healthcare Administration, or a related field (Master’s preferred).
• Minimum of 10 years of experience in claims operations, with at least 5 years in a senior leadership role.
• Proven experience in managing large, geographically dispersed teams.
• Strong knowledge of health insurance industry, including ACA, Medicare, Medicaid, Commercial, ASO, and DSNP.

Essential Duties and Responsibilities:

Strategic Leadership:

• Provide strategic direction and leadership for the claims operations department, aligning with organizational goals and regulatory requirements.
• Develop and implement strategic plans to achieve claims-related objectives and KPIs.
• Collaborate with executive leadership to drive continuous improvement initiatives and operational excellence.

Operational Oversight:

• Oversee the day-to-day operations of the claims department, ensuring efficient and accurate claims processing.
• Ensure timely and accurate configuration of provider contracts and benefits administration systems.
• Monitor and address operational issues promptly to maintain high service levels.

Team Leadership:

• Lead, mentor, and develop a high-performing team of managers and staff across various claims functions.
• Foster a culture of accountability, professional development, and continuous improvement.
• Provide guidance and support to direct reports, ensuring alignment with organizational goals.

Compliance and Reporting:

• Ensure compliance with state, federal, and industry regulations, including HIPAA and CMS guidelines.
• Prepare and present regular reports on claims performance, trends, and department metrics.
• Conduct audits and reviews to maintain high standards of accuracy and compliance.

Stakeholder Engagement:

• Build and maintain strong relationships with key stakeholders, including clients, providers, and internal departments.
• Serve as the primary point of contact for executive leadership on all claims-related matters.
• Collaborate with cross-functional teams to optimize processes and systems to support claims operations.

Project Management:

• Oversee the implementation of upgrades and new products related to claims systems.
• Facilitate effective inter-departmental communication to ensure the impact of procedural changes and system enhancements are fully understood.
• Prioritize objectives and tasks, set intermediate target dates, track project completion, and determine the most effective methods to accomplish project goals.