Claims Operations Director

Job Description

Job Description

Location: Tallahassee, FLDepartment: ClaimsFLSA: ExemptSchedule: As requiredAbout the role:We are seeking a Claims Operations Director to lead and oversee Capital Health Plan's end‑to‑end claims operations, including claims processing, other party liability (OPL) recoveries, premium billing and reconciliation, contract administration, and payment integrity functions.This role directs multiple operational teams and managers, ensuring the timely, accurate, and compliant processing of claims and premiums while maintaining the integrity of provider records, contract configurations, and reimbursement systems. The Claims Operations Director partners closely with senior leadership, cross‑functional teams, and third‑party vendors to drive operational performance, regulatory compliance, system enhancements, and continuous improvement across all claims‑related functions.We're looking for someone who has:Bachelor's degree from an accredited four-year college or university, or equivalent education and experienceSignificant leadership experience in claims operations, healthcare administration, or related functions; ten years of related experience preferredDemonstrated experience managing multi-disciplinary operational teams within a healthcare or payer environmentStrong working knowledge of claims administration, premium billing, contract configuration, and payment integrity processesAbility to develop workflows, productivity standards, and performance metrics to meet operational and regulatory goalsStrong analytical skills with experience using data to set KPIs and support senior leadership reportingThorough understanding of healthcare billing and coding concepts (e.g., CPT, ICD, revenue codes) Strong written and verbal communication skills, including the ability to present complex operational information to senior leadershipHighly preferred candidates also have:Experience overseeing Medicare reimbursement processes and adapting to regulatory changesExperience with provider contract administration and system configuration managementExperience managing software enhancements, reimbursement systems, or claims adjudication platformsFamiliarity with provider billing operations and dispute resolution processesStrong financial acumen, including basic accounting knowledge and reconciliation conceptsExperience leading cross-functional initiatives to improve claims, billing, or payment integrity outcomesAbout Capital Health Plan (CHP):CHP is a locally based, not‑for‑profit health maintenance organization serving the Tallahassee region for more than four decades. Founded by community leaders with a mission to deliver high‑quality, affordable, and patient‑centered health care, CHP has grown into a nationally recognized healthcare organization while remaining deeply rooted in the communities it serves.CHP is proud to be an Equal Opportunity Employer and is committed to maintaining a workplace that values professionalism, integrity, and respect. We provide equal employment opportunities to all employees and applicants and do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected status.

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