Director Of Claims

* Description
* Our client, a large public health plan, has a need for a contract to hire Director of Claims. The group includes 20 direct reports including 2 managers, Claims supervisor, Claims Adjusters and Examiners.
Much of the work includes support provider disputes, educationg providers and working through billing questions. The customer uses Epic Tapestry and you would have the opportunity to be trained on Epic.
Top priorities when you start the job: a large backlog of pending claims which are in jeopardy of pending interest, performance improbement initiative and optimization of the department workflows for greater efficiency.

Job Description:

Contra Costa Health is offering an excellent opportunity for a Claims Director. The Claims Director plays a leadership role within CCGP, providing strategic and operational oversight of the claims function to ensure accurate, timely, and compliant payment of healthcare services. This position is responsible for setting direction, establishing controls, and guiding continuous improvement across claims operations while supporting positive provider relationships, regulatory compliance, and the financial integrity of the health plan.
The Claims Director works closely with executive leadership and cross-functional partners to align claims operations, with accountability for claims adjudication, payment integrity, regulatory compliance, and vendor oversight across Medi-Cal, Medicare, and commercial lines of business. This role ensures claims operations support member access, provider relationships, and the financial integrity of the health plan.
About them:
They are a federally qualified, state-licensed, county-sponsored Health Maintenance Organization serving more than 250,000 residents. As part of the County's integrated public health system, plays a central role in delivering accessible, high-quality care to a diverse population. The primary business line is Medi-Cal, but also has a growing D-SNP product line as well as Commercial lines of business.
We are looking for someone who is:

* Experienced in Managed Care Leadership:
Brings extensive experience leading health plan claims operations within a managed care environment, including responsibility for complex, high-volume systems

* Knowledgeable in Medicaid and Medicare:
Demonstrates deep understanding of Medi-Cal and Medicare program requirements, including claims payment policy, audits, and regulatory oversight

* A Strategic Thinker:
Able to translate regulatory requirements and organizational priorities into sustainable operational strategies

* A Strong Communicator:
Clearly conveys complex claims, financial, and compliance issues to executive leadership, staff, providers, and external partners

* Solution-Oriented:
Proactively identifies operational risks and implements improvements that enhance accuracy, timeliness, and provider experience

* Professional and Collaborative:
Builds strong working relationships across finance, compliance, IT, utilization management, and external vendors

* Discreet and Judicious:
Exercises sound judgment in managing confidential, sensitive, and high-risk matters

* A People Leader:
Invests in leadership development, succession planning, and workforce stability
What you will typically be responsible for:

* Providing leadership and oversight of all CCHP claims operations, including claims adjudication, adjustments, payment integrity, and recovery activities

* Setting departmental strategy, goals, policies, and performance expectations aligned with CCHP's mission and regulatory obligations

* Directing, coaching, and evaluating managers and supervisors responsible for daily claims operations

* Overseeing third-party administrators, clearinghouses, and other claims-related vendors, including contract performance and issue resolution

* Directing the use and optimization of Epic Tapestry for claims adjudication, payment rules, edits, and reporting, and ensuring system changes are appropriately tested, documented, and implemented

* Implementing a claims editing software and establishing workflows to ensure payment integrity

* Ensuring full compliance with federal, state, and local regulations, including DHCS, DMHC, and CMS requirements

* Establishing and monitoring key performance indicators related to claims timeliness, accuracy, financial controls, and regulatory compliance

* Serving as the primary e liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies

* Representing the orginzation at DHCS, CMS, and DMHC audits

* Identifying operational risks, audit findings, and systemic issues, and ensuring timely corrective action and reporting to executive leadership

* Collaborating with Provider Relations, Contracts, Finance, Compliance, Utilization Management, IT, and Quality divisions to support integrated operations and organizational objectives

* Leading initiatives related to system enhancements, policy updates, and process redesign to improve claims efficiency and…