Director of Claims

214bf51a-c332-4680-9417-17fe2278d7e4•Phoenix, AZ

2d•Onsite

About The Position

The Director of Claims provides strategic and operational leadership for Adobe Population Health’s claims lifecycle, ensuring accurate, timely, and compliant claims submission, adjudication, payment, reconciliation, and collection. The role manages claims inventory, reduces denials and underpayments, resolves payer disputes, minimizes revenue leakage, and improves reimbursement performance across the organization’s payer portfolio. The Director works across departments to establish standardized billing procedures, monitor payer requirements, validate billing readiness, and implement processes that support accurate reimbursement and sustainable revenue cycle performance. The position uses claims data, analytics, process improvement, and technology to drive operational excellence, revenue integrity, and customer service, while building scalable processes that support organizational growth. This position is based at the Phoenix office and requires working in the office five days per week. Travel may be required as needed for operational needs, provider engagement, and business initiatives, at less than 5%.

Requirements

Seven years of progressive healthcare claims experience.
Three years of leadership experience managing claims, billing, collections, or reimbursement teams.
Demonstrated experience in claims operations, healthcare billing, revenue cycle management, reimbursement, or payer claims administration.
Strong understanding of claims submission, rejection and denial management, appeals, resubmissions, payer follow-up, collections, and accounts receivable.
Experience identifying and resolving underpayments, contractual payment discrepancies, aging claims, and revenue leakage.
Knowledge of payer billing requirements, reimbursement methodologies, contractual terms, and claims filing and appeal deadlines.
Experience monitoring claims KPIs, analyzing trends, developing action plans, and communicating financial and operational results.
Ability to lead cross-functional initiatives and coordinate effectively with Finance, Contracting, Clinical Operations, IT, and payer representatives.
Strong analytical and problem-solving skills, including investigating discrepancies, identifying root causes, and implementing sustainable solutions.
Ability to establish standardized procedures, internal controls, escalation pathways, and measurable performance expectations.
Strong written and verbal communication skills, including the ability to explain complex claims and reimbursement issues to technical and nontechnical audiences.
Organizational skills, attention to detail, sound judgment, and ability to manage competing priorities.
Ability to lead teams with professionalism, fairness, accountability, and respect for diverse perspectives.
Proficiency with claims management, billing, accounts receivable, reporting, and spreadsheet applications.
Ability to handle confidential information appropriately and comply with privacy and security requirements.
Ability to thrive in a fast-paced, rapidly growing healthcare environment.
Ability to travel as necessary for operational needs, provider engagement, and business initiatives (less than 5%).

Nice To Haves

Experience in population health, value-based care, managed care, provider services, community-based healthcare, or other healthcare service delivery environments.
Experience managing claims across multiple payers, states, programs, service lines, or reimbursement models.
Familiarity with Medicaid, Medicare, Medicare Advantage, commercial payer arrangements, and applicable claims requirements.
Experience with Electronic Data Interchange (EDI), particularly X12 837 claims and X12 835 remittance advice transactions.
Experience with automated claims edits, payment posting, electronic remittance processing, denial analytics, and revenue cycle reporting.
Experience supporting payer contract implementation, fee schedule validation, reimbursement testing, and operational billing readiness.
Experience with electronic health records, practice management platforms, claims clearinghouses, and financial or enterprise reporting systems.
Experience leading process improvement, system implementation, workflow standardization, or revenue recovery initiatives.
Demonstrated success improving clean-claim rates, reducing denials and aging inventory, increasing collections, or recovering underpaid claims.
Experience developing teams, establishing performance metrics, and managing organizational change.
Proficiency with healthcare revenue cycle platforms and financial systems, including Sage Intacct, Salesforce, Availity, Change Healthcare, and Microsoft Office Suite, or demonstrated ability to quickly learn comparable technologies.
Bachelor’s degree in healthcare administration, business administration, finance, accounting, health information management, or a related field preferred; equivalent relevant experience may be considered.
Ongoing professional development in healthcare reimbursement, payer requirements, claims technology, and revenue cycle best practices is encouraged.
Certified Revenue Cycle Executive (CRCE), Certified Healthcare Financial Professional (CHFP), Certified Professional Coder (CPC), Certified Professional Biller (CPB), or equivalent certification strongly preferred.
Relevant professional certifications in healthcare claims, revenue cycle management, medical billing, or healthcare finance preferred.
Lean Six Sigma certification preferred.

Responsibilities

Oversee the end-to-end claims lifecycle, including preparation, submission, adjudication, payment, reconciliation, correction, resubmission, and collection.
Manage claims inventory and establish workflows for submissions, rejections, denials, appeals, resubmissions, and follow-up.
Monitor claims aging and outstanding balances; prioritize claims and implement collection plans, including escalation of high-risk and high-value claims.
Ensure claims are submitted accurately and within payer and contractual filing deadlines; oversee corrections, appeals, reconsiderations, and resubmissions.
Analyze rejection and denial trends, investigate root causes, and implement prevention strategies, corrective actions, staff education, and system edits.
Lead payer follow-up and collection activities for unpaid, delayed, rejected, underpaid, and disputed claims.
Identify and resolve underpayments, payment discrepancies, contractual collection disputes, revenue leakage, and missed billing opportunities.
Collaborate with Finance to reconcile claims activity, remittances, accounts receivable, payment records, and expected revenue.
Partner with Contracting, Finance, Clinical Operations, and IT to ensure new or amended payer contracts and other changes are ready for billing.
Translate contractual requirements into operational workflows; validate readiness for new services, programs, providers, locations, payer arrangements, and contract changes.
Oversee claims testing and payer adjudication validation, investigate discrepancies, and maintain implementation and payer-specific documentation.
Monitor payment accuracy and Electronic Remittance Advice (ERA) processing; resolve 835 ingestion, mapping, posting, reconciliation, and other remittance exceptions with relevant teams.
Establish controls to identify unapplied or duplicate payments, incorrect adjustments, unexplained variances, and other payment discrepancies.
Establish, monitor, and report claims KPIs; develop dashboards, reports, and executive summaries that communicate performance, root causes, financial exposure, and recommended actions.
Set measurable performance goals and accountability for claims resolution, follow-up, collections, and process compliance; use analysis to prioritize improvements.
Evaluate workflows, systems, automation opportunities, and controls to improve accuracy, efficiency, scalability, and visibility.
Lead, coach, develop, and performance-manage claims and revenue cycle personnel; establish procedures, quality standards, and training.
Partner with Finance, Contracting, Clinical Operations, Quality, Compliance, IT, executive leadership, and payer representatives to resolve claims barriers and improve performance.
Communicate material claims risks, collection challenges, payer disputes, reimbursement trends, and improvement opportunities to leadership.
Ensure claims operations comply with applicable federal and state requirements, payer policies, contractual obligations, filing rules, organizational procedures, HIPAA, and privacy and security requirements.
Maintain claims documentation and support audit readiness, internal controls, internal and external audits, payer reviews, and corrective action initiatives.
Identify and escalate potential billing irregularities, inappropriate payment practices, recurring control failures, and other compliance concerns.
Participate in special projects and organizational initiatives as assigned.