TPA Claims Operations Leader

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

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.