Director, Claim Research & Resolution - JHP

Jefferson Health Plans • Philadelphia, PA

9d • Onsite

About The Position

The Director, Claims Research & Resolution, is responsible for leading the strategy, governance, and execution of complex claims issue identification, root cause analysis, remediation, and resolution. This role oversees a team of analysts and collaborates across Operations, Healthcare Economics, Configuration, Pricing, Provider Network, and other business areas to drive claims accuracy, regulatory compliance, financial integrity, and continuous process improvement.

Requirements

• High School Diploma/GED
• 7 years progressive experience in insurance claims administration, medical billing, or denials and appeals management
• 5 years experience in a supervisory or departmental management capacity, demonstrating the ability to lead large teams of analysts.
• Deep operational experience handling complex disputes, complex contract terms, and medical coding reconsiderations
• The ability to look past individual claim errors to identify systemic flaws in data feeds, provider billing habits, or internal auto-adjudication systems.

Responsibilities

• Provide leadership and oversight for the intake, investigation, prioritization, and resolution of complex claims issues impacting payment accuracy, provider experience, and operational performance.
• Direct root cause analysis efforts, leveraging cross-functional subject matter experts to identify systemic issues and implement sustainable corrective actions.
• Establish and maintain monitoring, tracking, and reporting processes to identify claims payment and denial trends, risks, and improvement opportunities.
• Assist with financial impact assessments and remediation strategies, including identification and correction of affected claims when necessary.
• Partner with internal stakeholders to ensure timely issue resolution, alignment of priorities, and accountability for corrective action implementation.
• Build, develop, and mentor a high-performing team while fostering a culture of accountability, collaboration, innovation, and continuous improvement.
• Directs the daily operations of the provider call center to ensure consistent adherence to service level agreements (SLAs), CMS compliance regulations, and state mandates.

Benefits

• medical (including prescription)
• supplemental insurance
• dental
• vision
• life and AD&D insurance
• short- and long-term disability
• flexible spending accounts
• retirement plans
• tuition assistance
• voluntary benefits
• tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: High school or GED