Senior Administrator of Claims

DETROIT WAYNE Integrated HEALTH Network; Detroit (MI); On-site; USD 110,000 - 160,000; Full time

Job summary

DETROIT WAY Integrated HEALTH Network seeks a Senior Administrator of Claims to provide strategic leadership and administrative oversight of the claims unit. You will assure accurate, timely adjudication and payment of provider claims in line with Medicaid/Medicare guidelines, MDHHS requirements, and contractual obligations.

In collaboration with executive leadership and cross-functional teams, you will develop policies, strengthen internal controls, monitor performance, and drive data-driven

Responsibilities

• Provide strategic direction and administrative oversight of the Claims Unit.
• Develop and evaluate goals, plans, and performance standards for claims processing.
• Direct daily claims intake, adjudication, payment processing, and reconciliation.
• Establish controls to ensure accuracy, timeliness, and compliance.
• Monitor KPIs, prepare management reports, and drive improvement initiatives.
• Coordinate with Finance and Compliance to resolve discrepancies.

Skills

Strategic leadership

Claims administration

Regulatory compliance

Audit readiness

Staff leadership

Financial oversight

Job description

About this position

Job Description

Job Title

Senior Administrator of Claims

Department

Administration

Reporting Structure

Deputy Chief Executive Officer

11

Exempt/Non-Exempt

Exempt

Bargaining Unit:

At-Will

Work Location

Varie s

Employment Status (FTE)

Full-Time

1.0

Job Summary

Under the general supervision of the Deputy CEO, the Senior Administrator of Claims provides strategic leadership, administrative oversight, and operational direction for the Detroit Wayne Integrated Health Network (DWIHN) claims administration function. This position is responsible for ensuring the accurate, timely, consistent, and compliant adjudication and payment of provider claims in accordance with applicable federal and state laws, Michigan Department of Health and Human Services (MDHHS) requirements, Medicaid and Medicare guidelines, DWIHN policies, provider contracts, and established reimbursement methodologies.

The Senior Administrator of Claims oversees the development, implementation, and continuous improvement of claims policies, procedures, systems, internal controls, quality assurance practices, and performance monitoring processes. The position promotes financial accountability, payment accuracy, appropriate utilization of resources, and equitable treatment of providers while safeguarding public funds and protecting the integrity of DWIHN's claims administration processes.

This position works collaboratively with executive leadership, finance, clinical operations, compliance, information technology, utilization management, provider network management, and other internal and external stakeholders to resolve complex claims issues, strengthen operational effectiveness, mitigate financial and regulatory risk, and support DWIHN's organizational objectives. The Senior Administrator of Claims is accountable for claims performance, staff leadership and development, vendor oversight, regulatory reporting, audit readiness, and the implementation of data-driven strategies that improve service delivery and operational efficiency.

Strategic Leadership and Claims Administration

• Provides strategic direction and administrative oversight of the Claims Unit, ensuring that claims operations align with DWIHN's organizational priorities, financial objectives, contractual obligations, and regulatory requirements.
• Develops, implements, and evaluates departmental goals, operational plans, performance standards, and long-term strategies to support accurate, timely, and efficient claims processing and payment.
• Establishes and maintains standardized claims administration policies, procedures, workflows, and operational controls to promote consistency, accountability, transparency, and equitable claims determinations.
• Directs the daily operations of the Claims Unit, including claims intake, review, adjudication, adjustment, payment processing, reconciliation, reporting, and resolution of outstanding claims issues.
• Establishes clear expectations for claims management staff and ensures accountability for productivity, accuracy, timeliness, quality, and compliance with established performance standards.
• Evaluates claims operations to identify systemic challenges, operational deficiencies, emerging risks, and opportunities for improvement, and implements corrective and preventive measures as appropriate.
• Provides executive leadership with timely updates regarding claims performance, significant operational issues, financial exposure, compliance risks, and recommended corrective actions.

Claims Accuracy, Payment Integrity, and Financial Accountability

• Oversees claims adjudication and payment processes to ensure that provider claims are processed accurately and in accordance with covered benefits, provider contracts, authorization requirements, coding standards, reimbursement policies, and applicable regulations.
• Establishes and monitors internal controls designed to prevent, identify, and address duplicate payments, inaccurate reimbursement, improper billing, overpayments, underpayments, inappropriate claims adjustments, and other payment integrity concerns.
• Ensures appropriate separation of duties and adequate internal controls between claims submission, review, adjudication, approval, payment authorization, reconciliation, and audit functions, as applicable.
• Establishes review and approval protocols for high-dollar claims, complex claims, manual adjustments, exceptions, and other transactions requiring elevated administrative oversight.
• Monitors claims expenditures, payment trends, outstanding liabilities, adjustments, recoveries, and other financial indicators to identify potential risks and support sound financial management.
• Collaborates with Finance and other appropriate departments to reconcile claims payments, investigate discrepancies, resolve payment variances, and ensure the integrity of claims-related financial data.
• Ensures that claims processing practices support the appropriate use of public funds and comply with applicable Medicaid, Medicare, MDHHS, contractual, and DWIHN requirements.
• Identifies opportunities to strengthen payment accuracy, reduce administrative waste, improve recovery processes, and mitigate inappropriate or unsupported expenditures.

Regulatory Compliance, Audit Readiness, and Risk Management

• Ensures claims operations comply with applicable federal and state laws, MDHHS policies and contractual requirements, Medicaid and Medicare regulations, HIPAA privacy and security requirements, and DWIHN policies and procedures.
• Develops and maintains claims-related policies, procedures, documentation standards, and internal controls necessary to demonstrate compliance with applicable regulatory and contractual obligations.
• Coordinates claims-related activities associated with internal audits, external audits, financial reviews, regulatory examinations, compliance assessments, and reviews conducted by MDHHS or other authorized entities.
• Oversees the development and implementation of corrective action plans in response to audit findings, claims processing deficiencies, compliance concerns, payment discrepancies, and identified control weaknesses.
• Coordinates with Compliance, Legal, Finance, Quality Management, and other relevant departments regarding claims-related investigations, regulatory inquiries, potential improper payments, and other matters requiring cross-functional review.

Performance Management, Quality Assurance, and Reporting

• Establishes and monitors key performance indicators (KPIs) and quality measures related to claims processing accuracy, payment timeliness, inventory levels, claims aging, error rates, adjustment activity, provider inquiries, appeals, and regulatory compliance.
• Directs the preparation, review, and timely submission of accurate management reports, operational dashboards, financial analyses, and regulatory reports required by DWIHN leadership, MDHHS, auditors, and other authorized entities.
• Analyzes claims data to identify trends, root causes, recurring errors, unusual billing patterns, processing inefficiencies, and opportunities to improve financial and operational outcomes.
• Develops and implements performance improvement initiatives to address identified gaps, strengthen claims quality, improve processing efficiency, and enhance accountability throughout the claims function.
• Ensures the integrity, completeness, accuracy, and timeliness of claims data maintained within DWIHN's information systems and reporting platforms.

Provider Relations, Dispute Resolution, and Stakeholder Collaboration

• Serves as a senior administrative point of contact for complex claims matters involving providers, delegated entities, internal departments, and other authorized stakeholders.
• Oversees the timely and consistent resolution of provider inquiries, disputed claims, payment discrepancies, claims adjustments, appeals, and escalated complaints in accordance with established policies and applicable requirements.
• Collaborates with Provider Network Management, Finance, Clinical Operations, Utilization Management