Director of Claims Analytics & Resolution

Jefferson Health; Jefferson Center (PA); On-site; USD 150,000 - 210,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

AD&D insurance

Short- and long-term disability

401(k) / Retirement plan

Tuition assistance

Job summary

Health Partners Plans, Inc. is seeking a Director of Claims Research & Resolution to lead strategy, governance, and execution for complex claims issues.

You will oversee a team of analysts, collaborate across Operations, Healthcare Economics, and other areas to improve accuracy, compliance, and financial integrity. The role includes directing root-cause analyses, monitoring trends, and implementing corrective actions while ensuring SLAs and CMS regulations are met.

Qualifications

• 7 years progressive experience in insurance claims administration, medical billing, or denials and appeals management.
• 5 years supervisory or departmental management experience leading large teams of analysts.
• Deep operational experience handling complex disputes, complex contract terms, and medical coding reconsiderations.

Responsibilities

• Provide leadership and oversight for the intake, investigation, prioritization, and resolution of complex claims issues impacting payment accuracy, provider experience, and operational performance.
• Direct root cause analysis efforts, leveraging cross-functional subject matter experts to identify systemic issues and implement sustainable corrective actions.
• Establish and maintain monitoring, tracking, and reporting processes to identify claims payment and denial trends, risks, and improvement opportunities.
• Assist with financial impact assessments and remediation strategies, including identification and correction of affected claims when necessary.
• Partner with internal stakeholders to ensure timely issue resolution, alignment of priorities, and accountability for corrective action implementation.
• Build, develop, and mentor a high-performing team while fostering a culture of accountability, collaboration, innovation, and continuous improvement.
• Directs the daily operations of the provider call center to ensure consistent adherence to SLAs and CMS compliance regulations.

Skills

Leadership

Claims research

Root cause analysis

Team leadership

Process improvement

Education

High School Diploma/GED

Job description

Health Partners Plans, Inc. is seeking a Director of Claims Research & Resolution to lead strategy, governance, and execution for complex claims issues.

You will oversee a team of analysts, collaborate across Operations, Healthcare Economics, and other areas to improve accuracy, compliance, and financial integrity. The role includes directing root-cause analyses, monitoring trends, and implementing corrective actions while ensuring SLAs and CMS regulations are met.