Director of Claims & Enrollment

denverhealth; Denver (CO); On-site; USD 180,000 - 240,000; Full time

Job summary

Denver Health is seeking a Director of Claims & Enrollment to lead the daily operations of claims, enrollment, and credentialing while providing strategic oversight of encounters and system configuration. The role focuses on compliance, operational integrity, and driving efficiency across multiple teams and vendor partners.

The position requires leadership to maintain accurate operations, improve processing outcomes, and drive continuous improvement in a complex regulatory environment.

Responsibilities

• Oversee daily operations of claims, enrollment, and credentialing in line with CMS, CO Medicaid, CO Division of Insurance requirements.
• Direct weekly/monthly encounters submissions, drive improvements to rejection rates and submission outcomes through vendor oversight.
• Balance operational continuity with ongoing improvements and problem solving across claims, enrollment, credentialing, encounters, and system configuration.

Job description

We are recruiting for a mission-driven Director of Claims & Enrollment to join our team! We're with you for life's journey. At Denver Health, purpose isn't just something we believe in-it's something we live every day, for life's journey.

Our Values

Respect | Belonging | Accountability | Transparency

Department

Managed Care Administration

Job Summary

As the Director of Claims and Enrollment, you will lead the daily operational management of claims, enrollment, and credentialing while also providing strategic oversight of encounters and system configuration functions. Primary accountability centers on keeping daily operations running accurately and in compliance, while simultaneously solving problems and driving continuous improvement across all areas. Encounters is a recurring weekly and monthly process where this role provides oversight and works to improve rejection rates and submission outcomes. System configuration is not an operational function but rather a strategic one, focused on driving improved claims processing configuration as well as managing seasonal and annual benefits configuration changes. You will provide direct oversight of four internal teams as well as vendor partners whose work supports a significant portion of the organization's operations. Managing vendor relationships in this role is the equivalent of overseeing dozens of additional resources, making vendor oversight a core and critical accountability. By leveraging your expertise, you will drive effective stakeholder communication, streamline issue resolution, ensure regulatory and contractual compliance, and introduce innovative solutions to enhance operational efficiency. This position requires a leader who can keep daily operations on track while identifying and solving problems across claims, enrollment, credentialing, encounters, and system configuration. Success in this role means maintaining compliance and operational integrity today while building toward a stronger, more efficient organization tomorrow.

Essential Functions :

Claims, Enrollment, Credentialing and Configuration Operations Management

• Oversee and manage the daily operations of claims, enrollment, and credentialing as the primary operational functions of this role. Adheres to and enforces the rules, regulations, and contractual requirements of CMS, CO Medicaid, CO Division of Insurance, contracted and non-contracted providers.
• Oversees the encounters submission process on a weekly and monthly basis, providing direction and driving improvements to rejection rates and acceptance outcomes through vendor oversight and process refinement. System configuration oversight is focused not on daily operations but on driving improved claims processing configuration and managing the seasonal and annual benefits configuration changes that directly impact claims adjudication accuracy.
• Approaches all areas with a problem solving mindset, balancing the need to keep operations running smoothly with the ongoing work of identifying and implementing meaningful improvements.

Manage vendor oversight program of outsourced activities to ensure the contractual performance meet expected outcomes including appropriate turnaround time, accuracy, quality assurance program(s), and issue resolution. To include

• Audit Planning and Execution:o Lead the planning and execution of audits to assess vendor performance, compliance, and adherence to contractual Service Levels and Key Performance Indicators.
• Conduct thorough risk assessments to identify potential areas for improvement and develop audit programs accordingly.
• Continuous Monitoring:o Establish and maintain a robust continuous monitoring framework to proactively identify and address emerging risks and issues related to vendor relationships.
• o Implement key performance indicators (KPIs) and metrics to measure vendor performance and compliance on an ongoing basis.
• o Leverage technology solutions for data analytics, automation, and reporting to enhance the efficiency and effectiveness of vendor auditing processes.
• Issue Resolution and Remediation:o Lead the resolution of issues identified through audits or other operational escalations, working collaboratively with cross-functional teams to implement corrective and preventive actions.
• o Monitor and track the progress of remediation efforts to ensure timely resolution of identified issues.
• Stakeholder Communication:
  • Regularly communicate audit findings, performance metrics, and risk assessments to senior leadership and key stakeholders.
  • Facilitate constructive dialogue with vendors to address concerns, provide feedback, and drive continuous improvement.

(60%)

Compliance and Regulatory Oversight

• Implement operational changes necessary to maintain compliance with regulatory guidance affecting internal teams and external vendors; guarantee the organization's adherence to all applicable laws and regulations.
• Oversee updates and changes to system configuration and team