Director I Claims

Director I Claims

Location: Tampa FL

Hours: Standard working hours

Travel: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Position Overview

Leads a large, complex Government Claims operation with end-to-end accountability across Medicare and Medicaid first-time claims, post-pay claims, provider inquiries and correspondence, and claim adjustment and sweep activity. This role is accountable for accurate and timely claim outcomes, regulatory and contractual compliance, audit readiness, service-level performance, and sustained operational improvement. The Director translates deep government program and claims expertise into disciplined execution, strong controls, effective issue resolution, and measurable improvements in efficiency and capacity. The role also serves as an operational leader for improving claims automation capabilities, strongly supporting or taking point on the development and execution of initiatives that materially improve claims performance while maintaining quality, compliance, and customer experience.

How You Will Make an Impact

• Providing a broad range of services needed by policy owners/clients and filed force to maintain in-force policies or new business
• Develops/implements complaint resolution procedures
• Develops short/long-term customer service objectives and continuously monitors procedures to ensure these are met by staff
• Ensures area is staffed and trained to handle inquiries from agents and policy owners
• Stays abreast of state and federal regulations and their impact on the industry
• Hires, trains, coaches, counsels and evaluates performance of direct reports
• Provide strategic and operational leadership across Medicare and Medicaid claims, including first-time claim processing, post-pay adjustments, corrected claims, provider inquiries, written correspondence, escalations, and mass-adjustment or sweep activity.
• Establish and maintain a management system that consistently meets or exceeds service-level agreements, prompt-pay requirements, performance guarantees, quality standards, inventory targets, and regulatory commitments.
• Use deep knowledge of Medicare and Medicaid policies, state and federal requirements, benefit and reimbursement rules, claims platforms, and operational workflows to guide complex claim decisions and resolve systemic issues.
• Own audit readiness and response for the assigned operation, including control design, evidence production, issue remediation, corrective action planning, and sustained monitoring of regulatory, client, internal, and external audit findings.
• Partner closely with technology, digital, analytics, payment integrity, provider operations, finance, compliance, audit, market, and vendor teams to deliver integrated solutions and remove barriers to operational performance.
• Build and maintain performance visibility through actionable metrics, trend analysis, capacity and demand planning, risk indicators, and executive-level reporting that clearly identifies drivers, decisions, and corrective actions.
• Ensure staffing, workflow allocation, training, documentation, and leadership routines are sufficient to manage changing volumes, regulatory requirements, and business priorities without compromising service or quality.
• Lead, develop, and hold accountable a multi-level organization; strengthen succession and talent pipelines while creating a culture of ownership, continuous improvement, regulatory discipline, and customer focus.

Required Qualifications

• Requires a BA/BS and 7 years leadership experience; or any combination of education and experience which would provide an equivalent background.

Preferred Qualifications

• Extensive leadership experience in health plan claims operations with direct responsibility for both Medicare and Medicaid lines of business.
• Demonstrated experience leading or serving as the operational point person for a claims automation initiative with measured impact to efficiency, productivity, capacity, quality, cost, or cycle time.
• Experience developing business requirements, partnering with technology and digital teams, supporting testing and implementation, managing operational readiness and adoption, and validating post-implementation benefits.
• Executive-level communication and cross-functional influence skills, with the ability to translate complex regulatory and operational issues into clear decisions, actions, and accountability.