Director, Claims System Configuration and Processing

What We Provide

• Referral bonus opportunities

• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays

• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability

• Employer-matched retirement saving funds

• Personal and financial wellness programs

• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care

• Generous tuition reimbursement for qualifying degrees

• Opportunities for professional growth and career advancement

• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Serves as enterprise Subject Matter Expert for Medicare and Medicaid benefit administration and complex payment policy.

• Evaluates efficiency of business processes; identifies, develops and implements solutions for improvement. Facilitates root cause analysis, project scope, and requirements documentation for claims system solutions.

• Establishes configuration for EDI gateway, claims systems, APC, DRG, Code Editing and FWA applications, and develops controls for system enhancements and new releases. Oversees test plan scenario development and user acceptance testing.

• Oversees annual configuration for benefits, pricing and codes. Ensures all new releases and enhancements are implemented within timeframes dictated by CMS, DOH or VNS Health CHOICE standards.

• Architects and validates claims system configurations to ensure full alignment with provider contracts, reimbursement methodologies, and benefit structures, minimizing financial leakage and ensuring contractual integrity

• Oversees onboarding and integration of new provider contracts and system interfaces (e.g., Symplr), ensuring automated and validated configuration workflows.

• Oversees VNS Health delegated entities to ensure claims processing is compliant with regulatory requirements, service level agreements and service excellence goals of VNS Health.

• Collaborates with Claims, Medical Management, Provider Relations, IT, and other required business areas to ensure support of operational areas.

• Manages claims system configuration issue resolution process. Analyzes existing operations and implements strategies and technological support to improve operational efficiency, productivity, and bottom-line results.

• Develops formalized audit methods for claims processing and system configuration, inclusive of benefits and pricing. Ensures that claims reports yield accurate and intended results for routine audits or upcoming site visit by CMS, DOH, DOI, and HEDIS. Presents periodic reports that detail performance, initiatives, and overall departmental progress to appropriate committees.

• Establishes and evaluates criteria for vendor selection and performance. Participates in selection of required products/services and acts within prescribed agency/organization guidelines. Prepares and negotiates contracts with outside vendors for consulting assignments. Monitors scope of project against deliverables.

• Partners with Compliance to translate state and federal mandates into system configuration logic and operational workflows.

• Leads preparation and response efforts for CMS, DOH, DFS, DOI, and other regulatory audits and complaint investigations.

• Directs claims payment integrity programs, including adjudication audits across all lines of business to ensure compliance with contractual, regulatory, and internal standards.

• Oversees recovery and cost-avoidance initiatives, including internal efforts and external vendor partnerships, to maximize return on investment and reduce overpayments.

• Oversees resolution of complex and high-volume provider claim disputes, focusing on systemic root cause remediation rather than transactional fixes.

• Provides financial reporting support to Finance related to claims accruals, liabilities, and outlier claims management.

• Establishes dashboards and performance indicators to monitor adjudication accuracy, financial exposure, audit risk, and operational efficiency.

• Directs development of training modules, SOPs, and UAT protocols to ensure operational readiness and knowledge transfer across teams.

• Oversees performance and integration of external audit and recovery vendors and strategic initiatives (e.g., MedEx, MCI), ensuring findings are validated and incorporated into systemic improvements.

• Performs all duties inherent in a senior managerial role. Approves staff training, hiring, promotions and terminations and salary actions, prepares and ensures adherence to the department budget. Attracts, develops, and retains highly talented delivery managers.

• Participates in special projects and performs other duties as assigned.

Education:

• Bachelor's Degree Business Administration, Healthcare Administration, related field, or equivalent work experience required
• Master's Degree Business Administration, Healthcare Administration, related field, or equivalent work experience preferred

Work Experience:

• Minimum of six years progressive experience in healthcare management claims and systems configuration required
• Claims processing system knowledge required
• Experience managing external audit and recovery vendors required
• Advanced knowledge of Medicare and Medicaid managed care reimbursement structures required
• Experience with financial accrual processes and claims liability reporting required
• Strong data analytics and business intelligence capabilities required
• Knowledge of HMO operations including claims, reimbursement methodologies and benefits administration required
• Knowledge of HIPPA EDI transactions and process required
• Ability to use standard methodologies in the analysis, design, development, evaluation, testing, documentation and implementation of system configuration required