Director, Claims Operations & Automation

Provider Network Solutions, LLC; Miami (FL); Hybrid; USD 150,000 - 230,000; Full time

Job summary

Provider Network Solutions, LLC in the United States seeks a Director of Claims Operations to lead end-to-end claims processing, benefit configuration, compliance, and performance management across health plan partnerships. This executive role drives automation, payment integrity, and continuous improvement at scale.

The role requires 7–10+ years in health insurance or TPA operations and expertise in regulatory frameworks, with a focus on improving efficiency, accuracy, and service delivery.

Qualifications

• 7–10+ years in TPA ops, managed care, health insurance, or specialty healthcare administration.
• Deep knowledge of end-to-end claims lifecycle: intake, adjudication, pricing, edits, denials, payment.
• Hands-on benefit configuration and reimbursement methodologies within payer/TPA.
• Strong regulatory knowledge: CMS, HIPAA, ERISA, state regs.
• Bachelor’s degree in healthcare administration, business, finance, or related field.

Responsibilities

• Lead enterprise claims operations strategy and execution, ensuring accuracy and compliance.
• Direct benefit configuration and claims system governance with change control and testing.
• Provide senior leadership and escalate complex issues while managing risk.
• Drive data-informed performance management, monitoring SLAs and KPIs.
• Champion technology modernization and automation to improve throughput and resilience.

Skills

Executive leadership

Decision making

Analytical thinking

Process improvement

Communication

Change management

Partnerships

Education

Bachelor’s degree in healthcare administration / business / finance

Tools

QNXT

Job description

Provider Network Solutions, LLC in the United States seeks a Director of Claims Operations to lead end-to-end claims processing, benefit configuration, compliance, and performance management across health plan partnerships. This executive role drives automation, payment integrity, and continuous improvement at scale.

The role requires 7–10+ years in health insurance or TPA operations and expertise in regulatory frameworks, with a focus on improving efficiency, accuracy, and service delivery.