Director – Claims and Encounters Operations
PacificSource Health Plans
full-time
Posted on:
Location Type: Remote
Location: Florida • Montana • United States
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Salary
💰 $108,469 - $184,397 per year
Job Level
About the role
- 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.
Requirements
- 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.
- 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.
Benefits
- Flexible telecommute policy
- medical, vision, and dental insurance
- incentive program
- paid time off and holidays
- 401(k) plan
- volunteer opportunities
- tuition reimbursement and training
- life insurance
- options such as a flexible spending account
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims processingencounter submissionoperational improvementworkflow designperformance managementclaims adjudicationdata analysiscost containmentregulatory complianceaudit readiness
Soft Skills
leadershipcoachingteam managementcollaborationcommunicationcapacity planningproblem-solvingstrategic planningperformance managementcontinuous improvement