Director of Claims Strategy & Operations

Prominence-Health-Plan; Reno (NV); On-site; USD 140,000 - 190,000; Full time

Benefits offered by this job

Loan Forgiveness

Generous PTO

Medical/Dental/Vision

401(k) match

Student loan refinancing

Career development

Job summary

Prominence Health, a value-based care organization, is seeking a Director of Claims to lead the strategic direction and execution of all claims operations. This role requires ensuring compliance with federal, state, and payer regulations while driving improvements in service delivery and efficiency.

The ideal candidate will have extensive Medicare/Medicaid claims experience, strong leadership, budget stewardship, and a track record of leveraging technology (QNXT preferred) to optimize

Qualifications

• Bachelor’s degree in healthcare administration or business management.
• 5+ years’ experience in claims management with direct Medicare claims experience.
• 5+ years’ experience managing, budgeting, forecasting and collaboration with executive leadership.
• Strong leadership skills with an ability to influence and persuade internally and externally while driving cross-functional collaboration.
• Deep understanding of medical terminology, coding systems (CPT, ICD-10), and insurance billing practices.
• Comprehensive knowledge of healthcare regulations, including HIPAA, CMS guidelines, state laws and experience in information preparation for required regulatory audits.
• Ability to promote data driven decision making throughout the organization.
• Knowledge of benefits, pricing and inventory management and reporting.
• Expertise in software implementation, technology adoption and an understanding of which tools work best to meet the needs of organization.
• Outstanding interpersonal skills
• Excellent written, oral, and active listening communication skills.
• Proficient in MS Office, contact center and training platforms, workforce management and project/team management software.
• Strong project management skills and experience managing large scale projects.
• Familiarity with claims systems and processes, QNXT system experience strongly preferred.

Responsibilities

• Lead strategic direction of claims operations and drive cross-functional initiatives.
• Ensure compliance with federal, state, and payer regulations across the organization.
• Drive innovation through technology and process optimization to improve service delivery and efficiency.
• Collaborate with executive leadership to align claims operations with organizational goals and budgets.

Skills

Leadership

Regulatory knowledge

Healthcare claims

Budgeting

Data-driven decisions

Communication

Project management

QNXT familiarity

Education

Bachelor’s degree in healthcare administration

Tools

QNXT

Job description

Prominence Health, a value-based care organization, is seeking a Director of Claims to lead the strategic direction and execution of all claims operations. This role requires ensuring compliance with federal, state, and payer regulations while driving improvements in service delivery and efficiency.

The ideal candidate will have extensive Medicare/Medicaid claims experience, strong leadership, budget stewardship, and a track record of leveraging technology (QNXT preferred) to optimize