SR Director - Claims Operations and Provider Configuration
We are a high-performing Managed Services Organization (MSO) supporting a Primary Care IPA operating under full-risk Medicare Advantage value-based care. We manage delegated claims, provider configuration, payment integrity, and key operational functions that ensure accurate, compliant, and efficient healthcare operations.
Position Summary
The Senior Director of Claims Operations & Provider Configuration is the operational leader responsible for end-to-end claims execution, provider setup/configuration, and claims system integrity within a fully delegated, full-risk Medicare Advantage environment.
This role ensures:
Providers are configured correctly
Claims adjudicate accurately and timely
Payment and risk arrangements are honored
Financial and regulatory standards are met
The Senior Director leads multiple teams, owns core KPIs, drives operational excellence, and partners cross-functionally across Finance, IT, Provider Engagement, Compliance, and Health Plans.
Key Responsibilities
Manage all claims functions: intake, adjudication, pricing, payment, adjustments, and reporting.
Improve first-pass adjudication, turnaround time, accuracy, and denial prevention.
Develop and enforce claims SOPs.
Manage escalations and systemic claims issues.
Partner with Finance on capitation, MLR, IBNR, and risk pool impacts.
Oversee provider setup including demographics, fee schedules, contracts, risk arrangements, and effective dates.
Maintain configuration accuracy for launches, transitions, and acquisitions.
Implement governance for configuration changes, QA, and issue prevention.
Work closely with Credentialing, Contracting, Eligibility, and EDI for data alignment.
Ensure correct payment aligned with contracts and value-based arrangements.
Identify and resolve overpayments, underpayments, and configuration-driven leakage.
Support recovery efforts, reconciliations, and audits.
Partner with FP&A and Actuarial on trends and cost forecasting.
Own KPIs such as:
First-pass adjudication rate
Claims accuracy
TAT
Configuration error rate
Dispute cycle time
Build dashboards, monitor trends, and implement improvements.
Ensure CMS, state, and payor delegation compliance.
Maintain documentation, SOPs, and audit-ready workflows.
Support and remediate findings from CMS, payor, and internal audits.
Lead and develop multiple operational teams.
Build a high-accountability, metrics-based culture.
Ensure proper staffing and succession planning.
Coach leaders on escalation and problem-solving.
Prepare operations for new markets, new payors, acquisitions, and system upgrades.
Lead automation and process optimization.
Support integrations and platform transitions.
Required Qualifications
Bachelor's degree in Healthcare, Business, or related field.
10+ years healthcare operations experience with deep claims expertise.
5+ years senior leadership experience in large, complex teams.
Hands-on SME in fully delegated, full-risk Medicare Advantage claims operations.
Strong expertise in:
Claims adjudication logic
Provider configuration & fee schedules
Delegated models & MA regulations
Proven track record driving KPI improvement and operational accuracy.
Ability to troubleshoot and resolve complex claims issues personally (not just oversight).
Preferred Qualifications
Master's degree (MHA, MBA).
Multi-state MSO/IPA experience.
Experience with growth, M&A, or systems migrations.
Strong working knowledge of EZ-Cap.
Lean/Six Sigma or similar process improvement training.
Core Competencies
Operational rigor and attention to detail
Strong analytical and financial acumen
Effective decision-maker in high-pressure situations
Clear communicator with technical and non-technical teams
Ability to turn strategy into scalable execution
All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.