Director of TPA Operations

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

Description

Position Summary

The Director of Claims Operations is responsible for leading end-to-end claims operations, benefit configuration, compliance, and performance management across health plan partnerships. This role provides strategic and operational leadership to ensure accurate, compliant, and efficient claims processing while driving automation, payment integrity, and continuous improvement at scale.

Duties and Responsibilities

• Lead enterprise claims operations strategy and execution, overseeing the full claims lifecycle to ensure accuracy, timeliness, cost containment, and compliance with contractual and regulatory requirements.
• Direct benefit configuration and claims system governance, translating health plan contracts, reimbursement methodologies, and benefit designs into scalable, accurate system logic while overseeing change control, testing, and release validation.
• Provide senior-level operational leadership and escalation management, resolving complex claims issues, adjudication exceptions, and cross-functional challenges while ensuring continuity, risk mitigation, and service level performance.
• Ensure regulatory compliance, audit readiness, and risk oversight, maintaining operational controls, supporting internal and external audits, and proactively adapting processes to regulatory and delegated oversight requirements.
• Oversee payment integrity, fraud prevention, and financial stewardship, partnering across compliance and investigative teams to reduce leakage, manage recoveries, and improve overall financial performance.
• Drive data-informed performance management and reporting, leveraging analytics to monitor SLAs, KPIs, utilization trends, and operational effectiveness while informing strategic planning and executive decision-making.
• Serve as the primary executive liaison for health plans and providers, leading operational reviews, governance forums, and escalations while maintaining strong, trusted external partnerships.
• Champion technology modernization, automation, and AI-enabled solutions, leading initiatives that improve throughput, accuracy, scalability, and long-term operational resilience.
• Lead organizational growth, change management, and team development, building scalable operating models, developing leadership talent, managing succession planning, and ensuring teams are prepared for system changes, regulatory shifts, and new partnerships.

Requirements

Knowledge

• 7–10+ years of progressive experience in TPA operations, managed care, health insurance, or specialty healthcare administration
• Deep knowledge of the end-to-end claims lifecycle, including intake, adjudication, pricing, edits, denials, and payment
• Hands-on understanding of benefit configuration and reimbursement methodologies within a payer or TPA environment
• Working knowledge of third-party administrator operating models, including acting as the intermediary between health plans and provider groups
• Strong understanding of payer contracts, fee schedules, benefit designs, and delegated vs. non-delegated arrangements
• Proficiency with claims administration platforms (e.g., QNXT, QuickCap, or equivalent)
• Strong regulatory knowledge, including CMS, HIPAA, ERISA, state insurance regulations, and payer compliance requirements
• Knowledge of audit standards and oversight, including internal audits, external audits, and delegated oversight reviews
• Familiarity with fraud, waste, and abuse (FWA) concepts, payment integrity controls, and SIU collaboration
• Bachelor’s degree in healthcare administration, Business, Finance, or related field (or equivalent experience)

Skills

• Executive-level leadership with the ability to drive accountability, performance, and cross-functional collaboration
• Strong operational decision-making and escalation management in complex, multi-stakeholder environments
• Advanced analytical capability to interpret claims, financial, and operational data and drive strategic action
• Proven ability to lead process improvement, operational efficiency, and cost containment initiatives
• Clear, confident communication with health plans, providers, auditors, executives, and internal teams
• Effective change management and ability to lead teams through growth, system enhancements, and regulatory change
• Strong partnership skills with technology, compliance, finance, and operations leaders to deliver enterprise outcomes