Claims Director

Position Summary

Unified Health Plan is seeking an experienced Director of Claims to lead our medical claims adjudication operations. This position is responsible for the accuracy, timeliness, consistency, and compliance of claims processing across the organization.

The Director of Claims will lead the claims team and oversee the full claims adjudication lifecycle, including claim intake, benefit application, eligibility verification, coordination of benefits, claim edits, payment determination, adjustments, appeals support, quality assurance, and operational reporting.

This is a hands-on leadership role for someone who understands self-funded health plan administration and can build a high-performing claims operation as Unified Health Plan continues to grow.

Key Responsibilities

Claims Operations

• Lead day-to-day medical claims adjudication operations for Unified Health Plan.
  
• Ensure claims are processed accurately and in accordance with plan documents, Summary Plan Descriptions, benefit configurations, administrative agreements, and applicable regulations.
  
• Oversee claim intake, eligibility validation, deductible and out-of-pocket accumulation, copays, coinsurance, benefit limits, exclusions, coordination of benefits, and payment determination.
  
• Ensure appropriate handling of in-network and out-of-network claims based on established plan rules.
  
• Oversee claim adjustments, corrected claims, reconsiderations, refunds, overpayments, and other post-adjudication activity.
  
• Establish clear procedures for complex, high-dollar, and exception claims requiring additional review.
  
• Ensure claims are processed within established turnaround-time and accuracy standards.
  
• Identify and resolve claims backlogs, workflow bottlenecks, and recurring processing issues.
  

Quality Assurance & Payment Accuracy

• Develop and maintain a comprehensive claims quality assurance program.
  
• Establish claims auditing standards and routinely monitor individual and departmental accuracy.
  
• Review error trends and implement corrective action, training, system configuration changes, or process improvements.
  
• Monitor payment accuracy and identify potential duplicate payments, incorrect benefit applications, overpayments, and underpayments.
  
• Partner with internal teams to resolve systemic claims issues.
  
• Establish measurable quality and productivity expectations for claims staff.
  
• Provide regular reporting on claims accuracy, turnaround time, inventory, productivity, aging, and other key performance indicators.
  

Claims System & Benefit Configuration

• Develop a strong understanding of Unified Health Plan's claims administration system and adjudication workflows.
  
• Partner with Systems, Data, Account Management, and Implementation teams to ensure benefit configurations accurately reflect plan documents and client requirements.
  
• Participate in testing of new benefit configurations and system changes before implementation.
  
• Identify opportunities to improve automation and reduce unnecessary manual claim intervention.
  
• Ensure claims processing rules and system configurations remain consistent with approved benefit designs.
  
• Assist with root-cause analysis when claims are adjudicated incorrectly due to system configuration or data issues.
  

Team Leadership

• Lead, coach, and develop claims supervisors, examiners, and processors.
  
• Establish clear performance expectations and hold team members accountable for accuracy, productivity, and service standards.
  
• Evaluate staffing needs and recommend appropriate staffing levels as claim volume grows.
  
• Develop training and continuing education programs for claims employees.
  
• Build standardized procedures and desk-level documentation that promote consistent claims handling.
  
• Foster a culture of accountability, accuracy, continuous improvement, and timely problem resolution.
  
• Conduct regular performance reviews and provide ongoing coaching and feedback.
  

Complex Claims & Escalations

• Serve as the senior operational resource for complex claims adjudication questions.
  
• Review high-dollar, unusual, or complicated claims when escalation is required.
  
• Partner with Account Management and Member Services to resolve escalated claim issues.
  
• Support appeals and benefit determinations by providing claims history, adjudication rationale, and operational expertise.
  
• Ensure escalated claims issues are evaluated for broader systemic impact rather than treated solely as individual corrections.
  

Compliance

• Ensure claims administration complies with applicable federal and state requirements and plan provisions.
  
• Maintain claims procedures and documentation necessary to support regulatory, client, stop-loss, and financial audits.
  
• Partner with Compliance on regulatory requirements affecting claims administration.
  
• Support requests for claims documentation associated with appeals, external reviews, audits, litigation, or regulatory examinations.
  
• Maintain appropriate segregation of duties and claims payment controls.
  
• Ensure claims decisions are appropriately documented and defensible.
  

Stop-Loss Support

• Partner with the Stop-Loss Coordinator and other internal teams to ensure high-dollar claims are identified and communicated timely.
  
• Support accurate and complete claim documentation needed for stop-loss submissions.
  
• Help identify potential large-claim exposure and ensure claims are adjudicated correctly before reimbursement submissions.
  
• Assist in resolving claim discrepancies that could impact stop-loss reimbursement.
  

Cross-Functional Leadership

• Work closely with Account Management, Customer Service, Finance, Compliance, Systems/Data, Utilization Management, and Implementation.
  
• Participate in new group implementations and renewals when claims administration considerations require operational input.
  
• Provide claims expertise when evaluating benefit designs and administrative processes.
  
• Communicate emerging claims trends and operational risks to executive leadership.
  
• Participate in strategic initiatives designed to improve scalability, member experience, and administrative efficiency.
  

Requirements

• Significant experience in health insurance, third-party administration, or self-funded medical claims operations.
  
• Strong working knowledge of medical claims adjudication.
  
• Experience leading claims employees in a supervisory, management, or director-level capacity.
  
• Strong understanding of deductibles, coinsurance, copays, out-of-pocket maximums, benefit limits, exclusions, coordination of benefits, and other medical plan provisions.
  
• Experience interpreting plan documents and translating benefit language into claims administration.
  
• Demonstrated ability to identify claim errors and determine root causes.
  
• Strong analytical and problem-solving skills.
  
• Experience developing operational controls, quality standards, and performance metrics.
  
• Strong written and verbal communication skills.
  
• Ability to manage multiple priorities in a growing organization
  

Benefits

• 90% employer-paid employee medical coverage
  
• Employer-paid dental coverage 
  
• Vision coverage available
  
• 7% employer 401(k) contribution
  
• Paid time off
  
• Employee Assistance Program (EAP)
  
• Health Savings Account (HSA)
  
• Gym/fitness benefit
  
• $10,000 employer-paid life insurance