Job Details

Job Title: Claims Director

Location: Onsite – Huntington Beach, CA

Type: 6-Month Contract-to-Hire

Position Overview

The Claims Director is responsible for managing claims operations, overseeing staff performance, and ensuring compliance with state and federal regulations. This includes supervising daily operations, leading quality assurance programs, and collaborating with executive leadership to align departmental strategies with organizational goals.

The ideal candidate will bring strong health plan claims experience, leadership skills, and a proven track record in process improvement.

Key Responsibilities

• Oversee daily operations of Claims Processing and Claims Payment Integrity departments.
• Lead and mentor management staff, providing coaching and professional development.
• Develop and implement strategic initiatives to improve KPIs and operational efficiency.
• Ensure compliance with CMS service-level agreements and regulatory requirements.
• Manage vendor relationships, including Third Party Administrators.
• Implement policies and procedures to ensure timely and accurate claims processing.
• Oversee claims system accuracy, including CPT, HCPCS, and diagnosis code updates.
• Monitor and optimize EDI clearinghouse contracts to reduce costs and paper claims.
• Deliver reports and analysis on claims flow, production, and quality.
• Collaborate with executives and cross-functional teams to ensure department alignment.

Minimum Qualifications

• Bachelor's degree required; Master's preferred.
• 5–7 years of health plan claims operations experience in a delegated model setting.
• At least 3 years in a leadership role.
• Strong knowledge of provider audit and payment methods, medical terminology, and claims documentation.
• Experience with health plan operations (claims configuration, utilization management, provider operations, customer service, etc.).
• Demonstrated ability to improve operational processes using data-driven approaches.
• Familiarity with CMS, state, and federal claims regulations.
• Experience with claims testing, auditing, and quality assurance.
• Strong analytical, organizational, and leadership skills.