Director, Claims and Encounters Operations

PacificSource Health Plans

7d•$108,469 - $184,397

About The Position

The Director of Claims and Encounters Operations is responsible for leading the day to day operations of claims processing and encounter submissions. This role partners with senior leadership to execute strategic priorities, ensure regulatory compliance, meet service level expectations, and drive operational efficiency across all lines of business, including Commercial, Medicare Advantage, and Medicaid. The Director oversees managers and frontline leaders, ensuring performance against contractual and regulatory requirements while continuously improving workflows, productivity, quality, and the overall customer experience.

Requirements

Minimum of 8 years of healthcare operations experience, with a strong focus on claims processing and/or encounters.
Minimum of 3 years of progressive leadership experience managing teams or managers in a healthcare operations environment.
Demonstrated experience in operational improvement, workflow design, and performance management.
Bachelor’s degree required.
Strong knowledge of claims adjudication, encounter submission, and processing systems.
Working knowledge of CMS regulations, state Medicaid requirements, and audit readiness practices.
Proven ability to lead teams through operational change and performance improvement.
Experience using data and metrics to drive accountability and results.
Ability to communicate effectively with leaders, peers, regulators, and frontline staff.
Strong problem solving, prioritization, and decision making skills.
Process improvement mindset with the ability to identify inefficiencies and implement practical solutions.

Nice To Haves

Experience working with Medicaid, Medicare Advantage, and Commercial lines of business strongly preferred.
Experience supporting or operating within a cost containment program preferred.
Preferred areas of focus: business, finance, healthcare administration, or a related field.
Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.

Responsibilities

Lead and manage daily operations for claims processing and encounter submissions across all lines of business.
Execute operational plans that align with organizational strategy, regulatory requirements, and performance expectations.
Ensure consistent achievement of government contractual Service Level Agreements (SLAs) and Commercial Performance Guarantees.
Monitor key performance metrics including productivity, quality, turnaround time, and inventory and implement corrective actions based on trends.
Partner with leadership on capacity planning, staffing models, and workload forecasting.
Design, implement, and refine scalable workflows for claims adjudication and encounter submission.
Identify and implement opportunities to reduce errors, improve first pass resolution rates, and increase operational efficiency.
Collaborate with Payment Integrity and vendor partners to ensure proper claim adjustments and financial accuracy.
Work with IT, Configuration, Compliance, Finance, and Product teams to define business requirements and support system enhancements for claims and encounters processing.
Ensure compliance with CMS, state, and federal regulations, including Medicare Advantage and Medicaid requirements.
Maintain readiness for audits, reviews, and regulatory reporting.
Oversee the development, maintenance, and adherence to policies, procedures, and internal controls related to claims and encounters.
Support continuous improvement initiatives focused on reducing Average Handle Time (AHT), rework, and operational backlog.
Lead, coach, and develop managers and staff through performance management, training, and succession planning.
Manage claims-related vendor relationships to ensure service quality and return on investment.
Participate in cross functional forums to support enterprise initiatives and operational alignment.
Meet department and company performance and attendance expectations.
Follow organizational privacy policies and comply with HIPAA laws and regulations regarding protected health information.
Perform other duties as assigned.