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The Director, Claims Research & Resolution, is responsible for leading the strategy, governance, and execution of complex claims issue identification, root cause analysis, remediation, and resolution. This role oversees a team of analysts and collaborates across Operations, Healthcare Economics, Configuration, Pricing, Provider Network, and other business areas to drive claims accuracy, regulatory compliance, financial integrity, and continuous process improvement.Job Description
- Provide leadership and oversight for the intake, investigation, prioritization, and resolution of complex claims issues impacting payment accuracy, provider experience, and operational performance.
- Direct root cause analysis efforts, leveraging cross-functional subject matter experts to identify systemic issues and implement sustainable corrective actions.
- Establish and maintain monitoring, tracking, and reporting processes to identify claims payment and denial trends, risks, and improvement opportunities.
- Assist with financial impact assessments and remediation strategies, including identification and correction of affected claims when necessary.
- Partner with internal stakeholders to ensure timely issue resolution, alignment of priorities, and accountability for corrective action implementation.
- Build, develop, and mentor a high-performing team while fostering a culture of accountability, collaboration, innovation, and continuous improvement.
- Directs the daily operations of the provider call center to ensure consistent adherence to service level agreements (SLAs), CMS compliance regulations, and state mandates.
QUALIFICATIONS
Education - Required
- High School Diploma/GED
Experience - Required
- 7 years progressive experience in insurance claims administration, medical billing, or denials and appeals management and
- 5 years experience in a supervisory or departmental management capacity, demonstrating the ability to lead large teams of analysts.
Knowledge, Skills and Abilities - Required
- Deep operational experience handling complex disputes, complex contract terms, and medical coding reconsiderations
- The ability to look past individual claim errors to identify systemic flaws in data feeds, provider billing habits, or internal auto-adjudication systems.
Work Shift
Workday Day (United States of America)Worker Sub Type
RegularEmployee Entity
Health Partners Plans, Inc.Primary Location Address
1101 Market, Philadelphia, Pennsylvania, United States of AmericaNationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.
Benefits
Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.
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