Director of Claims and Encounters

HJ Staffing • Albuquerque, NM

5d

About The Position

HJ Staffing is seeking a Director of Claims and Encounters to provide strategic leadership, fiscal accountability, and operational excellence. This executive role is responsible for directing Claims Operations for Commercial/ASO, Medicare, and Medicaid products. You will lead the Encounters Resolution team to ensure completeness and maximize Medicaid rate setting, driving operational strategy through accurate, timely, and efficient delivery.

Requirements

• Bachelor’s degree in Finance, Business, Healthcare, or a related field
• 10+ years of healthcare-specific operational leadership with a focus on Health Plan Claims Operations.
• 5+ years of experience leading within a complex, highly matrixed function.
• Deep understanding of Health Care industry operations, delivery models, and revenue models.
• Candidates must reside in one of the following states: NM, CA, IL, ND, NY, OH, WA, or WY.
• Previous experience within a Health Plan or Managed Care Organization is required.
• Candidates must be a US Citizen or Green Card holder.

Nice To Haves

• MBA preferred
• Experience with Jiva and HRP is highly preferred.

Responsibilities

• Strategic Leadership: Translate strategic goals into specific operating and resource plans. Drive the deployment of Auto-Adjudication methodologies and Robotic Process Automation (RPA/Bots).
• Operational Excellence: Oversee workforce planning, process improvement, and staff development for department managers and supervisors.
• Compliance & Quality: Ensure regulatory compliance across all areas, specifically driving NM Medicaid compliance for encounter metrics and Turnaround Times (TATs).
• Financial Stewardship: Monitor department budgets, manage monthly variance reporting, and maximize Medicaid rate-setting through encounter resolution.
• Technical Innovation: Partner with technical SMEs to enhance automation, innovation, and process simplification. Leverage BI tools and data visualization (Tableau) to provide decision support.
• Vendor Management: Manage key vendors to validate contract compliance on claims transactions and encounter acceptance measures.
• Cross-Functional Collaboration: Support the resolution of complex benefit and provider process issues, collaborating with Configuration, IS, Enrollment, and Member Services.

What This Job Offers

• Job Type: Full-time
• Career Level: Director