Director, Claims Management

Health Admins

. Lead the assigned third-party administrator medical claims operation under client service level agreements .

Posted 9/19/2026full-timeRemote • Texas • United StatesLeadWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive operational leadership in medical claims management, ensuring compliance with healthcare regulations and client service level agreements. Proficient in vendor management, team leadership, and data analysis to drive performance improvements.

Highest-signal resume keywords

Medical Claims ManagementVendor ManagementOperational LeadershipTeam LeadershipData Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Adjudication LogicICD-10 CodesCPT CodesHealthcare RegulationsSelf-Funded Employer Plan AdministrationClaims Management SoftwareHCSM Needs AdjudicationCost ContainmentRepricingMedical Review Processes

Soft Skills

Excellent Verbal CommunicationInterpersonal CommunicationAnalytical SkillsProblem-Solving SkillsTime Management

Tools & Technologies

Google SuiteSalesforce

Industry Keywords

Third-Party AdministrationHealth InsuranceClient Service Level AgreementsHealthcare ManagementERISACOBRAHIPAA

About the role

Key responsibilities & impact

Lead the assigned third-party administrator medical claims operation under client service level agreements
Ensure claims are processed accurately and within required timeframes
Run the two health share Needs teams, including intake, clinical review, processing, pay/deny/pend determinations, reimbursements, and runout
Meet and sustain client SLAs, including processing timelines of roughly 21 to 45 days or within 30 days of clean receipt
Own SLA tracking and responses when standards are at risk
Build toward traditional medical claims administration for self-funded employer plans
Lead Client Managers, Team Leads, and Coordinators across assigned teams
Own workload distribution, escalations, performance management, hiring, and staff development
Manage vendor relationships across clearinghouse, cost containment, medical review, staffing, and related functions
Oversee vendor performance and resolve disputes and issues
Develop hiring and staffing plans, fill approved headcount, and build bench depth
Oversee operational projects, including system and reporting changes, vendor implementations, and go-lives
Analyze claims data to identify trends, issues, and opportunities and implement data-driven improvements
Prepare and present operational and performance reporting to senior leadership
Maintain compliance with healthcare regulations, including ERISA, COBRA, HIPAA, and scope-of-practice requirements
Maintain high-quality client service and resolve operational client issues
Partner with Compliance, Benefits Administration, Client Services, and other internal stakeholders on audits, complex claims issues, regulatory changes, and operational excellence
Report to the VP of Operations
Travel occasionally as required

Requirements

What you’ll need

Bachelor's degree in Business Administration, Healthcare Management, or a related field, or equivalent experience
Minimum of 7 years of experience in medical claims management
At least 3 years in a leadership role in a TPA or health insurance environment
Demonstrated ability to lead and motivate a claims team, manage vendors, and own hiring and staffing for a multi-team operation
Proven operational leadership of a TPA or medical claims operation under client SLAs
Strong people leadership of Managers, Team Leads, and Coordinators
Vendor management skills
Excellent verbal, written, and interpersonal communication skills
Exceptional analytical and problem-solving skills
Solid time management skills
Must be a self-starter comfortable operating with broad accountability
Must adapt well to change and shifting priorities
Proficiency with Google Suite, including expert-level Documents and Sheets, Gmail, and Calendar
Comfortable operating in Salesforce as the system of record
Deep operational knowledge of third-party administration of medical claims and the full claims lifecycle
Knowledge of medical terminology, ICD-10 and CPT codes, and claims adjudication logic
Familiarity with clearinghouse, cost containment, repricing, medical review processes, claims management software, and vendor integrations
Working understanding of self-funded employer plan administration
Familiarity with HCSM Needs adjudication is helpful
Ability to maintain knowledge of healthcare regulations, insurance and cost-sharing rules, and industry best practices
Experience with Health Care Sharing Ministries or Medical Cost-Sharing programs is a plus, not required

Benefits

Comp & perks

Competitive salary and benefits package
Opportunities for professional growth and development
Remote work flexibility