Director of Claims

Job Description

Job Description

Job Purpose

The Director of Claims is responsible for overseeing and directing delegated claims operations to ensure accuracy, compliance, and efficiency. A key accountability of this role is the review of departmental reports to ensure accuracy and integrity of claims data, as well as collaborating with other departments to support accurate and timely reporting to health plans.

This role requires independent learning and initiative to identify opportunities for improvement, develop job aides, and drive productivity. The Director partners closely with the Claims Manager and VP of Finance to support audits, strengthen quality outcomes, create dashboard reporting, and contribute to the financial and operational success while upholding our Mission, Vision, and Values.

Essential Job Duties & Responsibilities

• Lead the Claims department, ensuring compliance with Medicare Advantage, managed care delegation, company policies, and regulatory requirements.
• Define and execute strategic goals to enhance claims accuracy, timeliness, efficiency, and alignment with organizational objectives.
• Manage, develop, and evaluate staff: set expectations, conduct performance reviews, coach, and address performance issues.
• Establish, maintain, and update policies, procedures, and productivity standards that guide departmental operations.
• Monitor key metrics (e.g. claim accuracy, processing speed, audit findings), identify trends or inconsistencies, and implement corrective actions.
• Prepare for audits by maintaining documentation, responding to findings, and ensuring data integrity.
• Collaborate with Contracting, Clinical, Finance, IT, and other stakeholders to integrate processes, reporting, and system changes.
• Communicate with internal and external partners (e.g. providers, delegated entities, payers) to resolve issues, support compliance, and ensure service quality.
• Keep current with regulatory/payer/delegation changes affecting claims processing and ensure these are incorporated into practices.
• Participate in budget/resource planning, process improvement initiatives, and other cross-departmental activities.
• Foster a culture of accountability, continuous learning, and collaboration within the department.

Experience

• 10 years in healthcare claims or revenue cycle management with at least 5 years of managerial experience.
• Strong analytical and problem-solving skills, with the ability to independently learn new concepts and apply them effectively.
• Ability to review, interpret, and validate complex reports and data sets.
• Excellent communication and interpersonal skills, with a focus on collaboration, team development, and influencing without direct authority.
• Medicare guidelines and healthcare claims regulation knowledge.
• Medicare Advantage claims adjudication is a plus.
• Familiarity with delegated claims audits and payer compliance requirements preferred.
• Proficiency in claims systems (e.g., EZCap, EZEDI, or similar) and Microsoft Excel. Experience with EMR software is a must.

Education

• Bachelor’s Degree in a related field is preferred. In lieu of degree, 10 or more years of relevant experience.

Knowledge, Skills & Abilities

• Proficiency with computers and PC applications
• Intermediate to advanced knowledge of Microsoft Excel and Office products.
• Possess extensive knowledge of billing regulations for Medicare, commercial, HMO’s and PPO’s.
• Knowledge of patient privacy and maintains confidentiality of all sensitive information.

Company Description

Who We Are:
Peyton Resource Group (PRG) has a 20-year track record of delivering real results for our clients. With offices in Dallas, San Antonio and Austin, PRG is an innovative industry leader utilizing the latest technology to drastically reduce the time-to-hire problem plaguing most companies today.
What We Do: We innovate. We understand. We collaborate. We move forward. We get IT done.

How We Do It:
We partner with world-class organizations that offer exciting career paths to their employees.
We cultivate relationships with the best and brightest talent in the marketplace.
We leverage technology in a way that is helping to redefine the staffing industry.
Our Results: We solve today's critical staffing challenges, while delivering best-of-class professionals to our clients.

Company Description

Who We Are:\r\nPeyton Resource Group (PRG) has a 20-year track record of delivering real results for our clients. With offices in Dallas, San Antonio and Austin, PRG is an innovative industry leader utilizing the latest technology to drastically reduce the time-to-hire problem plaguing most companies today.\r\nWhat We Do: We innovate. We understand. We collaborate. We move forward. We get IT done.\r\n\r\nHow We Do It:\r\nWe partner with world-class organizations that offer exciting career paths to their employees.\r\nWe cultivate relationships with the best and brightest talent in the marketplace.\r\nWe leverage technology in a way that is helping to redefine the staffing industry.\r\nOur Results: We solve today's critical staffing challenges, while delivering best-of-class professionals to our clients.