Director of Claims (Medical Claims)

Job PurposeThe Director of Claims is responsible for overseeing and directing delegated claims operations to ensure accuracy, compliance, and efficiency. A key accountability of this role is the review of departmental reports to ensure accuracy and integrity of claims data, as well as collaborating with other departments to support accurate and timely reporting to health plans.This role requires independent learning and initiative to identify opportunities for improvement, develop job aides, and drive productivity. The Director partners closely with the Claims Manager and VP of Finance to support audits, strengthen quality outcomes, create dashboard reporting, and contribute to the financial and operational success of HealthTexas while upholding our Mission, Vision, and Values.Culture and Values ExpectationsAt HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission "to deliver quality and compassionate care with outstanding service, every patient, every time". As a (Job Title) at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.Integrity: Do the right thing, the right way, every time.Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.Compassion: Treat everyone with respect and dignity.Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.Synergy: Collaborate to improve outcomes.Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.Stewardship: Use resources responsibly and efficiently.Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.Essential Job Duties & ResponsibilitiesLead the Claims department, ensuring compliance with Medicare Advantage, managed care delegation, company policies, and regulatory requirements.Define and execute strategic goals to enhance claims accuracy, timeliness, efficiency, and alignment with organizational objectives.Manage, develop, and evaluate staff: set expectations, conduct performance reviews, coach, and address performance issues.Establish, maintain, and update policies, procedures, and productivity standards that guide departmental operations.Monitor key metrics (e.g. claim accuracy, processing speed, audit findings), identify trends or inconsistencies, and implement corrective actions.Prepare for audits by maintaining documentation, responding to findings, and ensuring data integrity.Collaborate with Contracting, Clinical, Finance, IT, and other stakeholders to integrate processes, reporting, and system changes.Communicate with internal and external partners (e.g. providers, delegated entities, payers) to resolve issues, support compliance, and ensure service quality.Keep current with regulatory/payer/delegation changes affecting claims processing and ensure these are incorporated into practices.Participate in budget/resource planning, process improvement initiatives, and other cross-departmental activities.Foster a culture of accountability, continuous learning, and collaboration within the department.Other duties, as assigned.Experience10 years in healthcare claims or revenue cycle management with at least 5 years of managerial experience.Strong analytical and problem-solving skills, with the ability to independently learn new concepts and apply them effectively.Ability to review, interpret, and validate complex reports and data sets.Excellent communication and interpersonal skills, with a focus on collaboration, team development, and influencing without direct authority.Medicare guidelines and healthcare claims regulation knowledge.Medicare Advantage claims adjudication is a plus.Familiarity with delegated claims audits and payer compliance requirements preferred.Proficiency in claims systems (e.g., EZCap, EZEDI, or similar) and Microsoft Excel. Experience with EMR software is a must.EducationBachelor's Degree in a related field is preferred. In lieu of degree, 10 or more years of relevant experience.Knowledge, Skills & AbilitiesProficiency with computers and PC applicationsIntermediate to advanced knowledge of Microsoft Excel and Office products.Possess extensive knowledge of billing regulations for Medicare, commercial, HMO's and PPO's.Knowledge of patient privacy and maintains confidentiality of all sensitive information.Work Hours, Travel RequirementsMonday - Friday, 8:00 a.m. - 5:00 p.m., and as needed to complete projects.Travel to medical offices may be necessary for the purpose of providing benefit education. 

Created: 2025-10-01