[Hiring] Director, Claims and Encounters Operations @PacificSource

Role Description

The Director of Claims and Encounters Operations is responsible for leading the day-to-day operations of claims processing and encounter submissions. This role partners with senior leadership to execute strategic priorities, ensure regulatory compliance, meet service level expectations, and drive operational efficiency across all lines of business, including Commercial, Medicare Advantage, and Medicaid. The Director oversees managers and frontline leaders, ensuring performance against contractual and regulatory requirements while continuously improving workflows, productivity, quality, and the overall customer experience.

• Lead and manage daily operations for claims processing and encounter submissions across all lines of business.
• Execute operational plans that align with organizational strategy, regulatory requirements, and performance expectations.
• Ensure consistent achievement of government contractual Service Level Agreements (SLAs) and Commercial Performance Guarantees.
• Monitor key performance metrics including productivity, quality, turnaround time, and inventory and implement corrective actions based on trends.
• Partner with leadership on capacity planning, staffing models, and workload forecasting.
• Design, implement, and refine scalable workflows for claims adjudication and encounter submission.
• Identify and implement opportunities to reduce errors, improve first pass resolution rates, and increase operational efficiency.
• Collaborate with Payment Integrity and vendor partners to ensure proper claim adjustments and financial accuracy.
• Work with IT, Configuration, Compliance, Finance, and Product teams to define business requirements and support system enhancements for claims and encounters processing.
• Ensure compliance with CMS, state, and federal regulations, including Medicare Advantage and Medicaid requirements.
• Maintain readiness for audits, reviews, and regulatory reporting.
• Oversee the development, maintenance, and adherence to policies, procedures, and internal controls related to claims and encounters.
• Support continuous improvement initiatives focused on reducing Average Handle Time (AHT), rework, and operational backlog.
• Lead, coach, and develop managers and staff through performance management, training, and succession planning.
• Manage claims-related vendor relationships to ensure service quality and return on investment.
• Participate in cross-functional forums to support enterprise initiatives and operational alignment.

Qualifications

• Minimum of 8 years of healthcare operations experience, with a strong focus on claims processing and/or encounters.
• Minimum of 3 years of progressive leadership experience managing teams or managers in a healthcare operations environment.
• Demonstrated experience in operational improvement, workflow design, and performance management.
• Experience working with Medicaid, Medicare Advantage, and Commercial lines of business strongly preferred.
• Experience supporting or operating within a cost containment program preferred.
• Bachelor’s degree required. Preferred areas of focus: business, finance, healthcare administration, or a related field.
• Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.

Requirements

• Strong knowledge of claims adjudication, encounter submission, and processing systems.
• Working knowledge of CMS regulations, state Medicaid requirements, and audit readiness practices.
• Proven ability to lead teams through operational change and performance improvement.
• Experience using data and metrics to drive accountability and results.
• Ability to communicate effectively with leaders, peers, regulators, and frontline staff.
• Strong problem solving, prioritization, and decision making skills.
• Process improvement mindset with the ability to identify inefficiencies and implement practical solutions.

Benefits

• Accountable leadership.
• Business & financial acumen.
• Empowerment.
• Influential Communications.
• Situational Leadership.
• Strategic Planning.

Physical Requirements

• Stoop and bend.
• Sit and/or stand for extended periods of time while performing core job functions.
• Repetitive motions to include typing, sorting, and filing.
• Light lifting and carrying of files and business materials.
• Ability to read and comprehend both written and spoken English.
• Communicate clearly and effectively.