Director - Claims
Description
Title: Director – Claims
Department: Claims - Operations
About the Role:
The Director - Claims will be responsible for overseeing the end-to-end claims management
process, ensuring accuracy, efficiency, and compliance with regulatory standards. This role
involves leading a team of claims professionals, optimizing workflows, and driving strategic
initiatives to improve claims operations. The ideal candidate is an experienced leader with a deep
understanding of healthcare claims, payer-provider relationships, and a commitment to
delivering exceptional service.
What You’ll Do:
Leadership & Strategy
• Provide strategic direction for the claims department, aligning operations with company
goals and regulatory requirements
• Lead, mentor, and develop a high-performing claims management team
• Collaborate with executive leadership to establish and achieve claims-related KPIs and
financial targets
• Identify the root cause of any operational weaknesses and implement the best solution
• Serve as a thought partner to internal and external stakeholders to achieve mutual goals
Claims Management Operations
• Oversee end-to-end claims operations, claims processing, adjudication, and resolution to
ensure timeliness, accuracy, and compliance
• Develop, implement, review dashboards, reports, policies, procedures, and workflows to
optimize efficiency and mitigate errors
• Team accountability for areas such as – timeliness reporting to the health plans,
encounter reports, weekly inventory and workflow reports, and IPA claims summary
report for board meetings
• Monitor and address claim denial trends, providing actionable insights and corrective
strategies
• Manage relationships with payers, third-party administrators, and other key stakeholders
Compliance & Reporting
• Ensure compliance with state, federal, and industry regulations, including HIPAA and
CMS guidelines
• Prepare and present regular reports on claims performance, trends, and department
metrics
• Conduct audits and reviews to maintain high standards of accuracy and compliance
Qualifications:
• Bachelor’s degree in healthcare administration, business, or a related field (Master’s
preferred).
• 8+ years of progressive responsibility, preferably in a managed care setting
• Knowledge of DMHC, DHS, and CMS regulations and guidelines
• Proficient in knowledge of CPT, HCPCS, ICD-10,
• Strong knowledge of MSO operations, healthcare reimbursement models, and payerprovider dynamics.
Skills & Competencies:
• Expertise in claims processing systems and technologies (e.g., EHR, claims adjudication
software)
• In-depth understanding of healthcare regulations, including HIPAA and CMS guidelines.
• EZ-CAP software experience is a bonus
• Prior experience working in managed care/IPA setting
Who We Are:
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare
company accelerating the path towards a future where high-quality, coordinated healthcare is
available to all. We are building and operating an integrated, value-based healthcare delivery
platform to empower our physicians to provide the highest quality of end-to-end care for their
patients in a cost-effective manner, especially patients who are traditionally underserved and
those most vulnerable.
Our platform currently empowers over 10,000 physicians to provide care for over 1 million
patients nationwide. We have demonstrably improved patient outcomes: seniors on our platform
spend fewer days in the hospital than the national average and are readmitted less often, and
serve an extremely diverse community. Our rapid growth and unique position at the intersection
of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled
opportunity to combine clinical and technological expertise to improve patient outcomes,
increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Be Innovative
• Operate With Integrity & Excellence
• Work As One Team
Environmental Job Requirements and Working Conditions:
• This is a remote – US based position
• The base compensation target pay range for this role is: $140,000 - $150,000. This
salary range represents our national target range for this role.
Additional Information:
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action
employer. We do not discriminate based upon race, religion, color, national origin, gender
(including pregnancy, childbirth, or related medical conditions), sexual orientation, gender
identity, gender expression, age, status as a protected veteran, status as an individual with a
disability, or other applicable legally protected characteristics. All employment is decided on the
basis of qualifications, merit, and business need. If you require assistance in applying for open
positions due to a disability, please email us at [email protected] to
request accommodation.
The job description does not constitute an employment agreement between the employer and
employee and is subject to change by the employer as the needs of the employer and
requirements of the job change
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