Provide strategic leadership, fiscal accountability, and operational excellence
Direct Claims Operations for Commercial/ASO, Medicare, and Medicaid products
Lead the Encounters Resolution team to ensure completeness and maximize Medicaid rate setting
Drive operational strategy through accurate, timely, and efficient delivery
Oversee workforce planning, process improvement, and staff development
Ensure regulatory compliance across all areas, driving NM Medicaid compliance for encounter metrics
Monitor department budgets and manage monthly variance reporting
Partner with technical SMEs to enhance automation, innovation, and process simplification
Manage key vendors for claims transactions and encounter acceptance measures
Support the resolution of complex benefit and provider process issues, collaborating with other departments

Bachelor’s degree in Finance, Business, Healthcare, or a related field (MBA preferred)
10+ years of healthcare-specific operational leadership with a focus on Health Plan Claims Operations
5+ years of experience leading within a complex, highly matrixed function
Deep understanding of Health Care industry operations, delivery models, and revenue models
Experience with Jiva and HRP is highly preferred.

Director of Claims and Encounters

Key skills