Director of Claims and Encounters

HJ Staffing is seeking a Director of Claims and Encounters to provide strategic leadership, fiscal accountability, and operational excellence. This executive role is responsible for directing Claims Operations for Commercial/ASO, Medicare, and Medicaid products. You will lead the Encounters Resolution team to ensure completeness and maximize Medicaid rate setting, driving operational strategy through accurate, timely, and efficient delivery.

• Strategic Leadership: Translate strategic goals into specific operating and resource plans. Drive the deployment of Auto-Adjudication methodologies and Robotic Process Automation (RPA/Bots).
• Operational Excellence: Oversee workforce planning, process improvement, and staff development for department managers and supervisors.
• Compliance & Quality: Ensure regulatory compliance across all areas, specifically driving NM Medicaid compliance for encounter metrics and Turnaround Times (TATs).
• Financial Stewardship: Monitor department budgets, manage monthly variance reporting, and maximize Medicaid rate-setting through encounter resolution.
• Technical Innovation: Partner with technical SMEs to enhance automation, innovation, and process simplification. Leverage BI tools and data visualization (Tableau) to provide decision support.
• Vendor Management: Manage key vendors to validate contract compliance on claims transactions and encounter acceptance measures.
• Cross-Functional Collaboration: Support the resolution of complex benefit and provider process issues, collaborating with Configuration, IS, Enrollment, and Member Services.

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

• You have a proven track record of navigating and influencing within highly matrixed environments.
• You are an expert at diagnosing and resolving complex problems through a systems-thinking approach
  .
• You can effectively educate employees and transfer knowledge to improve functional effectiveness.
• You are skilled at communicating complex ideas and data-driven outcomes to various executive audiences.

• Residency Requirement: Candidates must reside in one of the following states:
  NM, CA, IL, ND, NY, OH, WA, or WY
  .
• Industry Requirement: Previous experience within a Health Plan or Managed Care Organization is required.
• Citizenship: Candidates must be a US Citizen or Green Card holder
  .