Director of Claims Operations (Healthcare TPA)

Position Overview

Concierge TPA specializes in self-funded, level-funded, Minimum Essential Coverage (MEC), and Per-Pay-Period (P3) health plans.

The Director of Claims Operations will lead the day-to-day performance and continued development of Concierge's claims operation. This role is responsible for ensuring claims are administered accurately, timely, and in accordance with plan documents and applicable regulations, while building the processes, systems, and team required to support continued growth.

The ideal candidate brings deep experience in TPA claims operations, particularly self-funded and level-funded health plans, and understands the broader ecosystem surrounding claims, including stop-loss, eligibility, PBMs, provider networks, appeals, compliance, and claims payment.

Key Responsibilities

1. Claims Operations & Performance

• Claims Leadership: Lead claims adjudication and administration across Concierge's health plan offerings.
• Performance Monitoring: Monitor claims accuracy, turnaround time, inventory, aging, and auto-adjudication rates.
• Quality Controls: Establish appropriate quality controls, claims audits, and performance reporting.
• Issue Resolution: Identify recurring errors, bottlenecks, and exceptions and drive corrective action.

2. Claims Oversight, Appeals & Large Claims

• Appeals Oversight: Oversee claims appeals, escalations, and complex claim reviews.
• Large Claims: Manage large-claim reporting and coordination with stop-loss carriers.
• Stop-Loss Reporting: Ensure timely and accurate delivery of required stop-loss information, including trigger reports, 50% reports, CPT codes, diagnoses, and supporting claims data.
• Reimbursement Tracking: Support appropriate tracking and follow-up of stop-loss reimbursements.

3. Eligibility & Member Support

• Eligibility Accuracy: Ensure enrollment and eligibility information supports accurate claims administration.
• Coverage Issues: Coordinate resolution of claims affected by eligibility changes, terminations, or coverage discrepancies.
• Service Standards: Ensure claims and benefit inquiries are handled consistently according to applicable plan documents, SBCs, and SPDs.
• Complex Support: Provide subject-matter support for complex member, provider, employer, and broker issues.

4. PBM, Network & Vendor Coordination

• PBM Coordination: Coordinate with PBMs on prescription claims, reporting, and claims-related issues.
• Network Performance: Monitor PPO discounts, claims repricing, and related reporting.
• Vendor Management: Partner with network, cost-containment, stop-loss, and other claims vendors to resolve issues and improve performance.

5. Compliance & Controls

• Regulatory Compliance: Ensure claims operations comply with applicable requirements, including ERISA, HIPAA, ACA, COBRA, and CMS regulations.
• Audit Readiness: Partner with Compliance to maintain appropriate claims processes, documentation, reporting, and audit readiness.
• Plan Adherence: Ensure claims decisions and processes are consistently supported by applicable plan documents.

6. Claims Automation & Team Leadership

• Claims Automation: Increase claims payment automation and auto-adjudication while maintaining appropriate quality controls.
• System Optimization: Partner with IT to optimize claims workflows, business rules, reporting, and integrations within VBA and related systems.
• Team Leadership: Lead and develop the claims team with clear expectations, accountability, training, and performance standards.
• Process Scalability: Build scalable, documented processes that reduce manual work and reliance on individual institutional knowledge.

Qualifications

Required

• 7-10 years of experience in health insurance, TPA, or healthcare claims operations.
• Significant experience overseeing claims adjudication and administration.
• Direct experience with self-funded and/or level-funded health plans.
• Demonstrated experience leading claims teams and managing claims quality, turnaround time, and operational performance.
• Strong working knowledge of stop-loss, eligibility, PBMs, provider networks, claims repricing, appeals, and large claims.
• Experience working with enterprise claims or TPA administration platforms.

Preferred

• Experience with VBA or a comparable TPA administration platform.
• Knowledge of relevant healthcare regulations, including ERISA, HIPAA, ACA, COBRA, and CMS requirements.
• Familiarity with healthcare EDI transactions, including 834, 837, 835, 270/271, and 276/277.
• Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field.
• CSFS, CEBS, PAHM, FAHM, or another relevant industry designation.

What Success Looks Like

The Director of Claims Operations will build a claims function that is accurate, timely, compliant, measurable, and increasingly automated. Leadership will have clear visibility into claims performance, the team will operate from consistent processes and standards, and Concierge will be able to support continued growth without adding manual complexity at the same rate as claims volume.

Benefits

Employer-paid health insurance

401(k) plan with employer contribution

Paid time off and holidays

Values That Guide Us

At Concierge, we’re dedicated to meeting our clients’ unique benefits administration needs. Our team strives to create long-term partnerships and meaningful connections based on shared values with those we serve.

Empower Others

We empower those we serve to have an active role in their benefit plan administration.

Deliver Responsive Service

Our timely, sincere approach extended to offering flexible services to those we serve.

Be Humble

Being humble helps us focus less on ourselves and more on delivering for you.

Live by the Golden Rule

We treat others the way we want to be treated—kindness, understanding and humility.

Provide Creative Excellence

We stay open-minded and willing to find new ways to solve problems as they appear.

Have Fun

Because life is meant to be lived with joy!