Claims Director

  • Full Time
  • Pasadena

Imperial Management Administrators Services

Strategic leader that can direct and oversee the Claims Department and assigned Claims staff to provide leadership with direction to ensure services are delivered accurately, timely and in accordance to contractual and regulatory requirements to client(s). Act as the primary liaison/consultant between client, health plans, regulatory agencies and Imperial Health teams, primarily system configuration and reporting, with regards to claims processing performance, accuracy, root cause analysis, systemic issues and failures as well as audits and corrective action plans. Participate in client on-site meetings as well as with internal and external operational teams, vendors and necessary business associates.


Responsible for determining, implementation and achievement of operational goals and key performance indicators related to implementation of new business lines and revenue recovery efforts for existing lines of business. Review claims metric and quality reports and analyze monthly reports. Understands, in detail, the daily, weekly, monthly and yearly metrics of the client needs and Claims Department and is able to make adjustments to meet goals/objectives.


Responsible to participate in and oversee CMS, health plan audits/assessments, responses and corrective action plans as it relates to clients. Analyze data, reports, systems and tools to identify opportunities for accuracy, efficiency improvements and drive root cause resolutions.


Work with the different Operations departments to develop and implement training to the claims staff related to client provider, client business rules and health plan contracts as well as regulatory changes. Responsible to recruit, hire, train staff, evaluate employee performance, and recommends or initiate promotions, transfers, and disciplinary actions for any direct reports.


This individual needs to be able to work independently, with little supervision; prioritizes, and manages multiple strategic and operational initiatives and tasks to meet client expectations and contractual obligations and deadlines. Seeks guidance from Vice President as needed to clarify performance, goals, accuracy thresholds, client requests, assignments or additional collaboration with internal departments.


Essential Duties And Responsibilities:

Maintain a full comprehensive understanding of the client services, contractual requirements, Federal and State regulations, covered benefits, coding guidelines, reimbursement policies and provider contract terms.
Ensure all benefit, provider, fee schedules, and DOFR rules are established correctly and audited periodically to ensure compliance with contracts through review of contract configuration within EZ-Cap to assure accurate payments to providers.
Perform root-cause analysis that may cause claims non-compliance/non-performance and lead, in collaboration with necessary operational departments, the implementation of resolutions.
Analyze operational impact and respond to complex escalated client and claims processing issues to ensure that client expectations and requirements are consistently met.
Review, create and or maintain workflows to ensure compliance and operational efficiency and develops and implements policies and procedures in collaboration with senior management.
Ensures compliance with Federal and State regulations and has oversight for all health plan audits.
Effectively organizes communication content and formats analyses to facilitate understanding and decision making by client and operational senior leaders.
Coordinates the production, development and delivery of materials for client meetings as well as collaborate with operational departments on the development and implementation of dashboards, scorecards, status reports for purposes of performance and analytical review.
Promote and contribute to a fair, positive and professional work environment through both management style and personal example.
Develop the policies, procedures, and workflows that are needed to maintain strict control over Claims processing, PDRs, Quality control, and Compliance.

This position reports to the Vice President of Operations, and requires a moderate degree of supervision to ensure strategic initiatives and client expectations are prioritized, met, and successfully implemented.



Knowledge of Health Plan Claims Operations, Managed Care and Risk Bearing Organizations
Effective writing, presentation and communication skills
Effective in influencing and negotiating – builds relationships and respect across functions and at all levels to gain support
Knowledge of industry regulations, laws, policies and regulations related to claims processing including CPT and ICD-10 guidelines
Advanced analytical skills demonstrated through the successful performance of numerous special analytical projects
Soft skills, including business partnering in a matrix organization
Ability to interpret requests/requirements and effectively present data to support performance improvement activities
Ability to prioritize and delegate work efforts, work independently, and leverage problem solving skills to research and resolve complex issues
Ability to work successfully under deadlines and client expectations
Requires an understanding of systems and processes that impact performance and capabilities
Possesses the ability to build trusting relationships with Client Executive Team
Possesses analytical ability to work in a data-heavy environment and to identify trends in the data
Possesses business acumen with an emphasis on: strategy, tactical execution, influencing decision makers, business planning, root cause analysis, problem solving, decision-making, effective communication, leadership and time management skills
Understanding of the regulators, health plans, hospitals, physician organizations, market, trends, competitors, and key pain points for health plan, hospital and physician organization executives
Proficient in MS Office: Outlook, Excel (Pivot Tables) Word, and PowerPoint)
Knowledge of EZ-Cap claims processing workflows, steps, auto-adjudication rules is necessary
Education / Experience

5 years of experience processing professional and facility healthcare claims
Bachelor’s Degree or the equivalent combination of training and experience is required
Must have at least 3-5 years of Managerial level experience
7 years of progressively higher responsibility experience in managed care and/or claims processing

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