Strategic Director, Claims Research & Resolution

Jefferson Health Plans; Philadelphia (Philadelphia County); On-site; USD 150,000 - 190,000; Full time

Benefits offered by this job

Medical insurance

Tuition assistance

Retirement plans

Job summary

Health Partners Plans, Inc. seeks a Director of Claims Research & Resolution to lead complex claims issue strategy, root cause analysis, and remediation across departments. You will oversee a team of analysts, drive process improvements, and ensure regulatory compliance while aligning with operational goals in a healthcare environment.

The role emphasizes governance, performance management, and cross-functional collaboration to improve payment accuracy and provider experience.

Qualifications

• 7 years of progressive claims administration experience.
• 5 years in supervisory or departmental management roles.
• Strong root cause analysis and cross-functional collaboration.
• Deep understanding of CMS regulations and provider payment processes.

Responsibilities

• Provide leadership for intake, investigation, prioritization, and resolution of complex claims issues.
• Direct root cause analysis with cross-functional SMEs to fix systemic issues.
• Establish monitoring and reporting to identify payment/denial trends and risks.
• Assist with financial impact assessments and remediation strategies.
• Partner with stakeholders to ensure timely resolution and accountability.
• Build and mentor a high-performing team promoting accountability and collaboration.
• Direct daily provider call center ops to meet SLAs and CMS/state requirements.

Skills

Complex disputes handling

Root cause analysis

Medical coding reconsiderations

Education

High School Diploma/GED

Job description

Health Partners Plans, Inc. seeks a Director of Claims Research & Resolution to lead complex claims issue strategy, root cause analysis, and remediation across departments. You will oversee a team of analysts, drive process improvements, and ensure regulatory compliance while aligning with operational goals in a healthcare environment.

The role emphasizes governance, performance management, and cross-functional collaboration to improve payment accuracy and provider experience.