Director Claims Management

CROWN ADMINISTRATORS•Austin, TX

6h•Remote

About The Position

Health Admins is a leading force in healthcare administration, on a journey to become a premier technology-driven healthcare platform. Our vision is anchored in a commitment to Getting Better Every Step of the Way. We are dedicated to providing innovative, efficient solutions that elevate the healthcare experience for the members and clients we serve. We are currently seeking a driven and experienced leader who acts with professional discipline and shares our passion for continuous improvement to join our team. Our ideal candidate will play a crucial role in managing our claims management environment, optimizing its performance, and driving continuous improvements to support our business goals and enhance our service delivery. Every Team Member is Driven by a Commitment to Live out These Values: * Operate as an Owner * Act with Professional Discipline * Pursue Progress Through Change * Treat Service as a Privilege Employees are expected to embrace our core values by being “A Hero in Action.” These values lay the foundation for the way we engage with each other and with our clients. They form the guardrails for our decision making and approach to problem solving.

Requirements

Proven operational leadership of a TPA or medical claims operation under client SLAs, with the judgment to make director-level decisions on escalations and staffing without waiting for direction.
Strong people leadership: able to lead Managers, Team Leads, and Coordinators, develop staff, and manage performance directly.
Vendor management skill, able to hold vendors to performance standards and resolve disputes across multiple concurrent relationships.
Excellent verbal, written, and interpersonal communication skills, with the presence to represent the operation to internal leadership and to hold client-facing service standards.
Exceptional analytical and problem-solving skills, able to read SLA and aging data, find the operational cause, and act on it.
Solid time management skills, able to run concurrent client operations, projects, and staffing work without dropping recurring obligations.
Must be a self-starter comfortable operating with broad accountability in a growing claims operation.
Must adapt well to change and set and adjust priorities as the operation and client demands shift.
Must be proficient with Google Suite (expert-level Documents and Sheets, plus Gmail and Calendar) and comfortable operating in Salesforce as the system of record.
Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience.
Minimum of 7 years of experience in medical claims management, with at least 3 years in a leadership role, in a TPA or health insurance environment.
Demonstrated ability to lead and motivate a claims team, manage vendors, and own hiring and staffing for a multi-team operation.
Deep operational knowledge of third-party administration of medical claims, including the full claims lifecycle: intake, adjudication, repricing, payment, member communication, and runout. Command of the point at which the processing clock starts on a clean claim or clean receipt, since client SLAs run from it.
Command of medical terminology, ICD-10 and CPT codes, and claims adjudication logic, with familiarity with clearinghouse, cost containment, repricing, and medical review processes. Working understanding of self-funded employer plan administration is valuable given the role's expected expansion.
Working proficiency in Salesforce as the system of record for cases and member escalations, and in Google Suite. Familiarity with claims management software and vendor integrations is expected.

Nice To Haves

Master's degree preferred.
Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, not required.
Familiarity with HCSM Needs adjudication (how sharing guidelines determine eligibility and sharing, and how to pay, deny, and pend outcomes) is helpful for the initial mandate but can be learned in role.

Responsibilities

Own full accountability for the assigned claims operation, ensuring claims are processed accurately and within required timeframes, and develop the strategies, staffing, and process improvements that keep it performing as volume grows.
Take over and run the two health share Needs teams as the initial mandate, including adjudication of member Needs across intake, clinical review, processing, pay/deny/pend determination, reimbursements, and runout.
Meet and sustain each client's service level agreements, which for the current health share teams range from processing within roughly 21 to 45 days to within 30 days of clean receipt. Own SLA tracking and the response when a standard is at risk.
Build toward and take on traditional medical claims administration for self-funded employer plans as the book expands, applying standard TPA claims practice across intake, adjudication, repricing, payment, and runout.
Lead the Client Managers, Team Leads, and Coordinators across the assigned teams. Own workload distribution, escalation handling, performance management, hiring, and staff development, fostering a high-performance, continuous-improvement culture.
Manage vendor relationships supporting the operation across clearinghouse, cost containment, medical review, staffing, and related functions. Own vendor performance and resolve disputes and issues.
Own hiring and staffing plans, including filling approved headcount, building bench depth for key roles, and partnering on comp benchmarking so the teams can hold SLAs as volume shifts.
Oversee active projects affecting the operation, including system and reporting changes, vendor implementations, and go-lives, serving as the operational owner while the project management function drives execution.
Analyze claims data to identify trends, issues, and opportunities, and implement data-driven improvements. Prepare and present operational and performance reporting to senior leadership.
Maintain up-to-date knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practice, and own compliance for the operation, including scope-of-practice questions for clinical review staff.
Maintain a seamless, high-quality client service experience, and own and resolve operational client issues on the assigned teams as they arise.
Maintain a comprehensive understanding of applicable federal and state regulations, including ERISA, COBRA, and HIPAA, to ensure claims administration and operational practices comply with all legal, regulatory, client, and organizational requirements.
Partner with Compliance, Benefits Administration, Client Services, and other internal stakeholders to support audits, resolve complex claims issues, implement regulatory changes, and promote operational excellence.