Director of Claims and Encounters

HJ Staffing is seeking a Director of Claims and Encounters to provide strategic leadership, fiscal accountability, and operational excellence. This executive role is responsible for directing Claims Operations for Commercial/ASO, Medicare, and Medicaid products. You will lead the Encounters Resolution team to ensure completeness and maximize Medicaid rate setting, driving operational strategy through accurate, timely, and efficient delivery.

What You Will Do

• Strategic Leadership: Translate strategic goals into specific operating and resource plans. Drive the deployment of Auto-Adjudication methodologies and Robotic Process Automation (RPA/Bots).
• Operational Excellence: Oversee workforce planning, process improvement, and staff development for department managers and supervisors.
• Compliance & Quality: Ensure regulatory compliance across all areas, specifically driving NM Medicaid compliance for encounter metrics and Turnaround Times (TATs).
• Financial Stewardship: Monitor department budgets, manage monthly variance reporting, and maximize Medicaid rate-setting through encounter resolution.
• Technical Innovation: Partner with technical SMEs to enhance automation, innovation, and process simplification. Leverage BI tools and data visualization (Tableau) to provide decision support.
• Vendor Management: Manage key vendors to validate contract compliance on claims transactions and encounter acceptance measures.
• Cross-Functional Collaboration: Support the resolution of complex benefit and provider process issues, collaborating with Configuration, IS, Enrollment, and Member Services.

What You Will Bring

• Education: Bachelor’s degree in Finance, Business, Healthcare, or a related field (MBA preferred).
• Experience: 10 years of healthcare-specific operational leadership with a focus on Health Plan Claims Operations.
• Leadership: 5 years of experience leading within a complex, highly matrixed function.
• Industry Knowledge: Deep understanding of Health Care industry operations, delivery models, and revenue models.
• Technical Plus: Experience with Jiva and HRP is highly preferred.

You Will Be Successful If:

• You have a proven track record of navigating and influencing within highly matrixed environments.
• You are an expert at diagnosing and resolving complex problems through a systems-thinking approach.
• You can effectively educate employees and transfer knowledge to improve functional effectiveness.
• You are skilled at communicating complex ideas and data-driven outcomes to various executive audiences.

Important Details

• Residency Requirement: Candidates must reside in one of the following states: NM, CA, IL, ND, NY, OH, WA, or WY.
• Industry Requirement: Previous experience within a Health Plan or Managed Care Organization is required.
• Citizenship: Candidates must be a US Citizen or Green Card holder.

Salary : $5 - $10