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Director, Claims Operations

Ferguson, MO · Healthcare
About the Company: 
A Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on underinsured and uninsured individuals.  Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans).  

The Company operates local health plans and offers a range of health insurance solutions.  It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.


Position Overview: 
Direct the day-to-day operations of the claims department and ensure accurate and timely processing of members medical claims within established state and company compliance guidelines.


Responsibilities: 
  • Develop the vision and goals for the claims department in compliance with federal, state and Company guidelines
  • Oversee and ensure achievement and maintenance of all claims processing standards within established guidelines
  • Partner with multiple business units, health plans and other stakeholders to establish operational objectives and procedures.
  • Identify business needs and drive change initiatives to address these issues
  • Ensure all issues are resolved accurately and timely and implement action plans to address any issues
  • Identify and implement operational efficiencies and development of “best practice” policies and procedures
  • Analyze customer impact and respond to complex escalated customer service and claims processing issues to ensure that customer expectations are consistently met

Required Qualifications: 
  • Bachelor’s degree or equivalent experience.
  • 7+ years of operations management, financial management or analysis, or claims operations experience, preferably in a managed care and/or Medicaid setting.
  • Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.

Benefits: 
The company offers more than just medical insurance. They pay most of your benefits costs and in some cases – they pay 100 percent. Most of the benefits not covered by the company are paid with pre-tax payroll deductions. 
  • Health insurance
  • Dental insurance
  • Vision insurance
  • Flexible spending accounts (includes health care, dependent care mass transit reimbursement)
  • Short- and long-term disability insurance
  • Basic Life insurance
  • Supplemental AD&D
  • Supplemental life insurance
  • Wellness Program
  • 401(k) retirement with company match
  • Employee stock purchase plan
  • Vacation, Personal and Sick time
  • Paid Company Holidays
  • Employee Assistance Program (EAP)
  • Training and Learning Opportunities
  • Tuition Reimbursement/Educational Assistance
  • Service Awards
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
Kat Forester
ProEnlist, LLC

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