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Director of Claims Processing - Remote
Full Time Senior Management CA-Fresno, Fresno, CA, US
6 days ago Requisition ID: 2381
Join BoldAge PACE and Make a Difference!
Why work with us?
- A People First Environment: We make what is important to those we serve important to us.
- Make an Impact: Enhance the quality of life for seniors.
- Professional Growth
- Access to training and career development.
Competitive Compensation:
- Generous Paid Time Off
- 401K with Match*
- Life Insurance
- Tuition Reimbursement
- Flexible Spending Account
- Employee Assistance Program
BE PART OF OUR MISSION!
Are you passionate about helping older adults live meaningful, independent lives at home with grace and dignity? BoldAge PACE is an all-inclusive program of care, personalized to meet the individual health and well-being needs of our participants. Our approach is simple: We listen to our participants and their caregivers to truly understand their needs and desires.
Director of Claims Processing
JOB SUMMARY
Reporting to the Chief Financial Officer, the Director of Claims Processing is responsible for strategic oversight, operational performance, and continuous improvement of the claims function. This role ensures accurate, timely, and compliant claims adjudication and payment processes, while driving efficiencies, mitigating risk, and enhancing provider and participant satisfaction. The Director partners cross-functionally with Finance, Compliance, Clinical Operations, and Health Plan leadership to align claims operations with organizational goals and regulatory requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Provide strategic leadership and oversight for all claims processing functions, ensuring alignment with organizational goals and regulatory requirements.
- Build, lead, and develop a high-performing claims team, fostering a culture of accountability, engagement, and continuous improvement.
- Establish and monitor key performance indicators (KPIs), dashboards, and reporting to track performance, identify trends, and mitigate risk.
- Oversee the end-to-end claims lifecycle, including intake, adjudication, payment, adjustments, and appeals, ensuring accuracy and timeliness.
- Ensure compliance with CMS, state Medicaid, and organizational guidelines, maintaining audit readiness and regulatory adherence.
- Monitor and optimize claims performance metrics, including turnaround time (TAT), denial rates, and rework, driving operational excellence.
- Lead process improvement and automation initiatives to enhance efficiency, scalability, and first-pass resolution rates.
- Partner with Compliance to support audits, investigations, and corrective action plans, and maintain strong internal controls to mitigate fraud, waste, and abuse.
- Manage and oversee relationships with third-party administrators (TPAs), clearinghouses, and external vendors, ensuring service quality and performance.
- Collaborate cross-functionally with Operations, Finance, Clinical, and Compliance teams to resolve escalations and complex claims issues.
- Serve as a key liaison between internal stakeholders and external partners, ensuring alignment and effective communication.
- Partner with Finance to ensure accurate claims payments, reserves, budgeting, and financial reporting, while identifying cost containment opportunities.
- Drive continuous improvement and adoption of industry best practices, including system enhancements and workflow redesign.
EXPERIENCE AND EDUCATION:
- Bachelor's degree in Healthcare Administration, Business, Finance, or related field required
- 7–10+ years of progressive experience in claims processing, healthcare operations, or health plan administration
- 3–5+ years in a leadership role managing claims teams
- Experience in PACE, Medicare/Medicaid, or managed care strongly preferred
- Experience working with TPAs or outsourced claims vendors
- 1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring (If applicable for the role).
PRE-EMPLOYMENT REQUIREMENTS:
- Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
- Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
- Employment with BoldAge PACE is contingent upon successful completion of post-offer pre-employment screening and verification processes
BoldAge PACE provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
- Match begins after one year of employment
