Director, Business Systems Claims Implementation

Title: Director / Senior Manager - Healthcare Systems & Provider OperationsLocation: Irving, TX (Hybrid - 3 days onsite / 2 days remote)Employment Type: Full-TimeIndustry: Healthcare / Payer (Medicare Advantage, Managed Care)OverviewWe are seeking a Director / Senior Manager of Healthcare Systems & Provider Operations to lead strategic initiatives across claims systems, provider data, credentialing, and benefit configuration. This role will drive system implementations, operational efficiency, and regulatory compliance within a payer environment.The ideal candidate brings deep expertise in claims platforms, provider operations, and Medicare Advantage, along with strong leadership experience managing cross-functional teams and large-scale system initiatives.Key ResponsibilitiesLead end-to-end implementations and enhancements of healthcare claims systems (Facets, HealthAxis, or similar)Oversee provider operations, including credentialing, provider data management, and network configurationDrive benefit configuration, pricing methodologies, and claims adjudication optimizationPartner with business and IT teams to deliver system integrations (EDI, vendor systems, APIs)Lead UAT cycles, system releases, and production deploymentsEnsure compliance with CMS, NCQA, HIPAA, and other regulatory standardsIdentify opportunities to improve auto-adjudication rates and reduce manual claims processingManage and mentor cross-functional teams (20+ resources) across operations and systemsDevelop and implement policies, procedures, and governance frameworksCollaborate with executive leadership on strategic planning, budgeting, and roadmap developmentRequired Qualifications10+ years of experience in the healthcare payer operations and overseeing the implementation of those systemsStrong expertise in:Claims systems (Facets, HealthAxis, or similar)Provider operations and credentialingBenefit configuration and pricing methodologiesExperience working within Medicare Advantage / Managed Care environmentsProven track record of leading system implementations and integrationsStrong understanding of CMS, NCQA, and regulatory compliance requirementsExperience managing large teams and cross-functional stakeholdersExcellent communication and leadership skillsPreferred QualificationsExperience with:EDI transactions (837, 835, etc.)Provider data platforms and credentialing systems (eVips, CAQH, Quest Analytics)Claims auto-adjudication optimizationBackground in healthcare digital transformation or modernization initiativesExperience working with startups or high-growth healthcare organizationsPMP or similar leadership certification

Created: 2026-05-09