Director, Claims

Altais

5d•$129,000 - $154,800

About The Position

At Altais, we’re on a mission to improve the healthcare experience for everyone—starting with the people who deliver it. We believe physicians should spend more time with patients and less time on administrative tasks. Through smarter technology, purpose-built tools, and a team-based model of care, we help doctors do what they do best: care for people. Altais includes a network of physician-led organizations across California, including Brown & Toland Physicians, Altais Medical Group Riverside, and Family Care Specialists. Together, we’re building a stronger, more connected healthcare system. About the Role Are you looking to join a fast-growing, dynamic team? We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients. This position is responsible for providing strategic leadership, as well as developing and controlling all day-to-day operations. Oversight for the following functions: claims processing, claims appeals, and claims recovery. This leader will oversee the design and optimization of operational processes, performance management/improvement, establish procedural standards, and manage both internal teams and vendor relationships to ensure adherence to KPIs and SLAs. This role requires close collaboration with IT, vendors, and cross-functional business teams to drive continuous operational and technical improvements. The Director will also provide leadership in automation initiatives aimed at reducing costs and improving financial outcomes, while ensuring compliance with CMS and state regulatory requirements with emphasis on Knox Keene requirements. The Claims department is responsible for processing claims and claim appeals per company policies, benefit plans, reimbursement schedules and managed care service/regulatory objectives for timeliness and accuracy. The ideal candidate will bring strong leadership, analytical, and project management skills, with experience in claims operations and healthcare regulatory compliance. This role will also be responsible for presenting initiatives to executive leadership, overseeing performance monitoring, and ensuring timely and high-quality execution of all Claims Operations activities.

Requirements

10+ years related experience
Bachelor's Degree or equivalent experience required.
7+ years in a leadership role
5+ years of experience with BPO/BPaaS solutions
Experience scaling operational teams
Demonstrated success leading claims transformation, automation, or process improvement initiatives
Advanced knowledge of and working experience with healthcare coding conventions such as ICD-10, CPT, and HCPCS
Thorough understanding of Commercial/Medicare Advantage claims rules/regulations.
Experience developing and managing department budgets.
Proven ability to build and lead high-performing operational teams, manage performance, and drive operational excellence

Nice To Haves

Experience with Epic Tapestry, HealthRules Payor and/or other claims systems
Experience with system integration and/or replacement while maintaining performance metrics

Responsibilities

Lead and scale end-to-end claims operations, including but not limited to: intake, adjudication, payment accuracy, and appeals coordination.
Optimize or establish performance standards and drive operational excellence across cycle time, cost per claim, accuracy, auto-adjudication rate, inventory backlog, and productivity metrics.
Develop workforce planning models and resource strategies to support changing claim volumes and future growth.
Supports the planning and execution of corporate operations strategy and multi-year roadmap, with a strong focus on near-term opportunities that improve claims accuracy and deliver positive in-year healthcare cost impact.
Lead continuous improvement initiatives focused on reducing administrative costs and improving turnaround times with a high focus on automation.
Develop dashboards and performance reporting to support executive decision-making.
Oversees BPO/BPaaS relationships supporting claims operations, including performance monitoring to operational KPIs and service level agreements.
Build, mentor, and retain high-performing operational teams.
Leads teams through change, building capability to anticipate, adapt, and execute effectively.
Supervises team operations including inventory management, reporting, workflow design, and quality control; monitors performance, identifies improvement opportunities, implements corrective actions, and delivers monthly operational reviews to leadership highlighting metrics, trends, and process improvements.