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TEKsystems · 23 hours ago

Director Of Claims

Martinez, CA

Full-time

Hybrid

Lead/Staff, Director/Executive

$75/hr - $80/hr

5+ years exp

TEKsystems is a leading provider of business and technology services, and they are seeking a Director of Claims for a large public health plan. The Claims Director will provide strategic and operational oversight of the claims function, ensuring accurate, timely, and compliant payment of healthcare services while managing a team and optimizing workflows.

Information Technology

Responsibilities

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 liaison for claims-related matters with providers, county partners, auditors, and regulatory agencies

Representing the organization 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 transparency

Qualification

Claims ManagementClaims ProcessingMedicaid KnowledgeMedicare KnowledgeEpic TapestryRegulatory ComplianceLeadership DevelopmentStrategic ThinkingCommunication SkillsProblem Solving

Required

Possession of a Bachelor degree from an accredited college or university with a major in business administration, finance, accounting or a closely related field

Five (5) years of full-time or its equivalent experience as an administrator or manager in a health care organization, at least three (3) years of which must have been in either a patient financial services, patient business services, patient accounting, or insurance billing and collections

Possession and maintenance of one of the following professional certifications: Certified Healthcare Financial Professional (CHFP) issued by the Healthcare Finance Management Association (HFMA) or Certified Patient Account Manager (CPAM) or Certified Clinic Account Manager (CCAM) certifications issued by the American Association Of Healthcare Administrative Management (AAHAM); or Certified Patient Account Technician (CPAT) or Certified Clinic Account Technician (CCAT) combined with additional four (4) years of qualifying experience can be substituted for the required education

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

Delivering Results: Achieving organizational and regulatory goals through strong operational leadership and accountability

Legal & Regulatory Navigation: Interpreting and applying complex laws, regulations, and guidance

Ownership & Accountability: Taking responsibility for outcomes and ensuring follow-through across teams

Handling Stress: Maintaining composure and sound judgment under pressure and competing priorities

Oral Communication: Effectively communicating complex information to executive and external audiences

Technology Leadership: Guiding the effective use of claims and payment systems to support operational performance, data integrity, and regulatory requirements, while partnering with IT on system enhancements and upgrades