Director of Claims & Enrollment

Denver Health•Denver, CO

1d•$140,000 - $231,000

About The Position

The Director of Claims & Enrollment leads daily operations for claims, enrollment, and credentialing and provides strategic oversight of encounters and system configuration. The role ensures accurate, compliant operations while identifying and implementing improvements across these functions. It oversees weekly and monthly encounters submissions, works to improve rejection and acceptance outcomes, and guides claims-processing configuration and seasonal and annual benefit configuration changes. The Director provides direct oversight of internal teams and vendor partners supporting significant operational activities. Vendor oversight includes auditing, risk assessment, continuous monitoring, performance measurement, issue remediation, and communication of findings to leadership and stakeholders. The role also ensures regulatory and contractual compliance, coordinates with internal partners on claims and provider issues, and manages staff training, performance, and development. This is a regular, full-time position with day-shift hours. The listed salary range is $140,000 to $231,000 per year.

Requirements

Bachelor's degree required.
Seven to ten years in a leadership role in claims and enrollment management and oversight, including benefit configuration and process-flow implementation and maintenance for commercial and government product lines.
Experience managing claims processing for Medicare and Medicaid.
Demonstrated ability to create approaches, policies, and procedures that support effective claims payment and adjudication at a health plan.
Solid system development and evaluation abilities, effective leadership and management, and strong written and oral communication skills.
Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules and regulations issued by CMS and Colorado HCPF.
Knowledge of claims forms and coding types, including UB-04, CMS 1500, ICD-9, ICD-10, HCPC, Revenue Codes, and NDC coding, as well as HIPPA, HEDIS, and NCQA.
Knowledge of bundled payments, risk-sharing, and provider capitation.
Proficiency with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems.
Ability to lead effectively and evaluate processes for efficiency.
Experience supervising staff and ensuring key tasks and goals are completed on time.

Nice To Haves

Experience with CHP+, Large Group Commercial, or Healthcare Exchange.
Experience in credentialing operations.
Experience and proficiency with Trizetto QNXT.

Responsibilities

Oversee daily claims, enrollment, and credentialing operations and ensure compliance with applicable rules, regulations, and contractual requirements.
Oversee weekly and monthly encounters submissions and improve rejection rates and acceptance outcomes through vendor oversight and process refinement.
Guide claims-processing system configuration and seasonal and annual benefit configuration changes to support accurate claims adjudication.
Plan and execute vendor audits assessing performance, compliance, service levels, and key performance indicators.
Conduct vendor risk assessments and develop audit programs to address areas for improvement.
Establish continuous monitoring frameworks and use performance measures to track vendor performance and compliance.
Use technology, data analytics, automation, and reporting to improve vendor auditing processes.
Lead resolution of audit findings and operational escalations, and track corrective and preventive actions through completion.
Communicate audit findings, performance metrics, and risk assessments to senior leaders and stakeholders, and work with vendors to address concerns and drive improvement.
Implement operational changes needed to maintain compliance with regulatory guidance and applicable laws and regulations.
Oversee changes to system configuration and operating procedures so claims processing and payment align with Utilization Management policies.
Collaborate with Contracting to confirm claims comply with contracts and with Provider Relations to resolve inconsistencies.
Develop, revise, review, and implement policies and procedures for pricing changes, contractual modifications, and adjustments.
Monitor for potential fraud and abuse and share findings with Payment Integrity and Compliance teams.
Direct internal teams and vendor partners supporting claims, system configuration, enrollment, encounters, and credentialing.
Manage Claims Operations staff and Claims and Enrollment Managers, including hiring, training, supervision, evaluation, and development.
Develop, review, and present productivity and accuracy reports.
Create training programs and ensure staff and vendors understand and follow claims policies and procedures.

Benefits

Paid time off starting at 28 days per year, including vacation, personal/sick time, and seven holidays.
100% paid parental leave for up to six weeks.
Immediate eligibility for retirement plans with employer contributions up to 9.5%.
Medical, dental, and vision plans, plus employer-paid disability and life insurance.
Well-being programs, including an on-site employee fitness center and RESTORE Center.
Free RTD EcoPass for public transportation.
Childcare discount programs and discounts on brands, travel, and other perks.
Tuition reimbursement and assistance.
Education, coaching, and professional development opportunities through the Workforce Development Center, supporting career growth and advancement.
Professional clinical advancement program and shared governance.
Public Service Loan Forgiveness-eligible employer, with free student loan coaching and assistance navigating the program.
National Health Service Corps and Colorado Health Service Corps eligible employer.