Director Claims Management

About Us

Health Admins is a leading force in healthcare administration, on a journey to become a premier technology-driven healthcare platform. Our vision is anchored in a commitment to Getting Better Every Step of the Way. We are dedicated to providing innovative, efficient solutions that elevate the healthcare experience for the members and clients we serve. We are currently seeking a driven and experienced leader who acts with professional discipline and shares our passion for continuous improvement to join our team.

Our ideal candidate will play a crucial role in managing our claims management environment, optimizing its performance, and driving continuous improvements to support our business goals and enhance our service delivery.

Every Team Member is Driven by a Commitment to Live out These Values:

• Operate as an Owner
• Act with Professional Discipline
• Pursue Progress Through Change
• Treat Service as a Privilege

Employees are expected to embrace our core values by being “A Hero in Action.” These values lay the foundation for the way we engage with each other and with our clients. They form the guardrails for our decision making and approach to problem solving.

The Director of Claims Management is the accountable operational leader for a third-party administrator (TPA) medical claims operation. The role runs a multi-team claims operation under client service level agreements (SLAs), owns delivery quality, and manages the staff, vendors, and projects that keep claims processing accurate and on time. The Director reports to the VP of Operations. This role may require occasional travel.

• Own full accountability for the assigned claims operation, ensuring claims are processed accurately and within required time frames, and develop the strategies, staffing, and process improvements that keep it performing as volume grows.
• Take over and run the two health share Needs teams as the initial mandate, including adjudication of member Needs across intake, clinical review, processing, pay/deny/pend determination, reimbursements, and runout.
• Meet and sustain each client's service level agreements, which for the current health share teams range from processing within roughly 21 to 45 days to within 30 days of clean receipt. Own SLA tracking and the response when a standard is at risk.
• Build toward and take on traditional medical claims administration for self-funded employer plans as the book expands, applying standard TPA claims practice across intake, adjudication, repricing, payment, and runout.
• Lead the Client Managers, Team Leads, and Coordinators across the assigned teams. Own workload distribution, escalation handling, performance management, hiring, and staff development, fostering a high-performance, continuous-improvement culture.
• Manage vendor relationships supporting the operation across clearinghouse, cost containment, medical review, staffing, and related functions. Own vendor performance and resolve disputes and issues.
• Own hiring and staffing plans, including filling approved headcount, building bench depth for key roles, and partnering on comp benchmarking so the teams can hold SLAs as volume shifts.
• Oversee active projects affecting the operation, including system and reporting changes, vendor implementations, and go-lives, serving as the operational owner while the project management function drives execution.
• Analyze claims data to identify trends, issues, and opportunities, and implement data-driven improvements. Prepare and present operational and performance reporting to senior leadership.
• Maintain up-to-date knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practice, and own compliance for…