Director of TPA Operations

Provider Network Solutions LLC; Miami (FL); On-site; USD 120,000 - 170,000; Full time

Job summary

Provider Network Solutions LLC in Miami, FL seeks a Director of Claims Operations to lead end-to-end claims processing across health plan partnerships. Drive automation, compliance, and performance at scale while guiding change management and team development.

The role demands 7–10+ years in TPA/healthcare administration, deep claims lifecycle knowledge, and strong leadership to optimize accuracy, costs, and service levels.

Qualifications

• 7–10+ years in TPA/healthcare administration or managed care.
• Deep knowledge of end-to-end claims lifecycle (intake, adjudication, pricing, edits, denials, payment).
• Hands-on understanding of benefit configuration and reimbursement methodologies.

Responsibilities

• Lead enterprise claims operations strategy and execution across full lifecycle, ensuring accuracy, timeliness, cost containment, and compliance.
• Oversee benefit configuration and claims system governance, translating contracts into scalable logic and managing change control, testing, and release validation.
• Provide senior leadership and escalation management to resolve complex claims issues and cross-functional challenges.
• Ensure regulatory compliance, audit readiness, risk oversight, and adapt processes to regulatory requirements.
• Oversee payment integrity, fraud prevention, and financial stewardship, reducing leakage and improving performance.
• Drive data-informed performance management and reporting, monitoring SLAs, KPIs, and utilization trends to inform strategy.
• Serve as executive liaison for health plans and providers, leading governance forums and escalations.
• Champion technology modernization, automation, and AI-enabled solutions to improve throughput and scalability.
• Lead organizational growth and change management, building scalable operating models and developing leadership.

Skills

Executive leadership

Operational decision-making

Data analytics

Process improvement

Communication

Change management

Partnership skills

Education

Bachelor’s degree in healthcare administration, Business, Finance, or related field

Tools

QNXT

QuickCap

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