Sr Director of Claims Operations & Configuration

The Senior Director of Claims Operations & Provider Configuration is a senior operational leader responsible for end-to-end claims execution, provider setup/configuration, and claims system integrity across a fully delegated, full-risk Medicare Advantage environment.

This role is accountable for ensuring that providers are configured correctly, claims adjudicate accurately, capitation and risk arrangements are honored, and downstream financial, clinical, and regulatory impacts are tightly controlled
.

Reporting to the VP of MSO Operations
, this role serves as the day-to-day executive owner of claims operations and provider configuration
, translating strategic direction into scalable execution. The Senior Director will lead multiple teams, own critical KPIs, partner cross-functionally with Finance, IT, Provider Engagement, Compliance, and Health Plans, and ensure operational readiness for growth, audits, and new market or payor expansion.

• Claims Operations (Professional, Institutional, Ancillary)
• Provider Configuration & Fee Schedule Management
• Delegated Claims Adjudication Accuracy & Timeliness
• Payment Integrity & Financial Controls
• Claims Systems, Rules Engines, and Configuration Governance
• Regulatory & Delegation Compliance
• Operational Scalability & Process Optimization

• Own end-to-end claims operations
  , including intake, adjudication, pricing, payment, adjustments, reprocessing, and reporting.
• Ensure high first-pass adjudication rates
  , accurate pricing, and timely payment in alignment with CMS, state, and payor delegation requirements.
• Establish and enforce standard operating procedures (SOPs) for all claims workflows.
• Monitor and manage claims inventory, backlog, turnaround time (TAT), and denial trends.
• Serve as the escalation point for complex claims, systemic errors, and provider disputes
  .
• Partner with Finance to ensure claims activity aligns with capitation, IBNR, MLR, and risk pool expectations
  .

• Own provider configuration across all claims and delegation systems
  , including:
• Contract terms
• Effective dates and terminations
• Ensure configuration accuracy prior to provider go-live
  , acquisitions, migrations, or payor transitions.
• Establish a formal configuration governance framework
  , including validation, QA, and change control.
• Partner closely with Credentialing, Contracting, Eligibility, and EDI teams to ensure data consistency across platforms.
• Ensure claims payment aligns with contractual terms, risk arrangements, and value-based incentives
  .
• Identify and mitigate over payment, underpayment, and claims leakage risks
  .
• Support recovery initiatives, payment corrections, and reconciliation efforts.
• Collaborate with FP&A and Actuarial teams on claims trend analysis, cost forecasting, and variance explanations.
• Support internal and external audits related to claims accuracy and provider payment.

• Define, track, and continuously improve core claims and configuration KPIs, including but not limited to:
• First-pass adjudication rate
• Claims turnaround time (clean vs. non-clean)
• Claims accuracy rate
• Rework percentage
• Provider dispute cycle time
• Develop dashboards and operational reporting for VP of MSO Ops, CFO, and executive leadership.
• Use data to proactively identify trends, risks, and improvement opportunities.

• Ensure ongoing compliance with:
• State regulatory requirements
• Support health plan audits, CMS audits, and internal compliance reviews
  .
• Maintain audit-ready documentation, policies, and workflows.
• Partner with Compliance to remediate findings and implement corrective action plans (CAPs).
• Lead and develop managers and senior staff across claims operations and provider configuration.
• Build a high-accountability, metrics-driven culture
  .
• Ensure appropriate staffing models aligned with volume, complexity, and growth.
• Coach leaders on problem-solving, escalation management, and continuous improvement.
• Drive succession planning and talent development within the department.

• Prepare claims and configuration operations for:
• New payor launches
• New market or state expansion
• IPA growth and acquisitions
• System migrations or upgrades
• Lead automation and optimization initiatives to reduce manual effort and error rates.
• Serve as an operational lead during integrations, transitions, or platform changes.

• Bachelor’s degree in Healthcare Administration, Business, Finance, or related field
• 10+ years of healthcare operations experience
  , with significant depth in claims operations
• 5+ years in a senior leadership role managing managers and complex teams
• Demonstrated experience in fully delegated, full-risk Medicare Advantage environments
• Deep understanding of:
• Provider configuration and fee schedules
• Medicare Advantage regulations
• Proven ability to…