Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

 

Primary Purpose

The Director of Claims Operations has overall responsibility and accountability for effectively and efficiently leveraging staffing, technology, and vendor relationships to lead claims processing and service operations. Establish the strategic direction for the claims business unit, integrating various components of the operation to achieve developmental and organizational goals. By fostering operational excellence and optimizing resources, the role ensures the delivery of accurate, timely, and compliant claims services that align with regulatory standards and organizational objectives.

 

Minimum Specifications

 

Education

Bachelor’s degree in healthcare administration, business, or a related field required. Master’s degree preferred.

 

Experience

Minimum of 8 years of experience in claims operations, with at least 5 years in a leadership role. Proven experience with Texas Medicaid/CHIP programs. In-depth knowledge of QNXT claims systems, including configuration, reporting, and troubleshooting. Experience with regulatory compliance and audits in a Medicaid/CHIP environment.

 

Equivalent Education and/or Experience

May have an equivalent combination of education and/or experience in lieu of specific education and/or experience as stated above.

 

Certification/Registration/Licensure

Project management or Six Sigma certification preferred.

 

Skills or Special Abilities

Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms. Demonstrated ability to coach and influence for results. Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization. Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals. Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups. Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities. Strong analytical and problem-solving skills. Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual. Sound business acumen. Proficient Microsoft Office and computer skills.

 

Responsibilities

Strategy

Develop and execute strategic initiatives and programs to enhance existing claims functions and implement new processes that support organizational goals and regulatory requirements. Oversee strategic analysis and accuracy of the claims process, ensuring compliance with Texas Medicaid/CHIP regulations and contract requirements for all lines of business.

               

Operations

Direct and oversee all claims operations, including front-end processing, special pricing, benefit configuration, audits, and testing. Oversee claims queue management, pended claims resolution, and ensure processing accuracy to meet organizational objective. Monitor claims inventory, cycle times, and work quality to maintain compliance with contractual and regulatory standards. Ensure accurate and timely adjudication of claims in compliance with Texas Medicaid/CHIP regulations. Optimize QNXT claims system workflows and troubleshoot operational issues. Collaborate with IT and system vendors for enhancements and updates. Oversee claims processes for delegated vendors and maintain alignment with organizational policies and standards.

 

Quality

Integrate health literacy principles into all communication including Members and Providers. Support strategies that meet clinical, quality and network improvement goals. Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed. For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

               

Regulatory

Develop processes to maintain compliance with regulatory agencies and accrediting bodies. Ensures operations are carried out in compliance with these regulations. Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards. Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary. Works collaboratively with leadership and/or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary. Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies.

 

Fiscal Management and Operating Budget

Operationally responsible for the financial performance of assigned area(s). Promote activities to achieve operational efficiency. Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets. Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs. Manage staffing levels within established targets.

 

Talent Management

Provide direction to the Claims Operations team and oversee staff performance, development, and goal setting. Mentor and support professional growth while fostering a culture of accountability and excellence. Recruit and retain diverse talent with a variety of backgrounds, skills, experiences, and viewpoints that reflect the communities we serve. Promote and support a culturally welcoming, inclusive, collaborative, and highly engaged work environment where everyone feels empowered to bring their full, authentic selves to work. Accountable for orientation, ongoing education and training, and competency verification for all employees. Ensure Human Resource metrics (i.e., retention, vacancy, engagement) meet established targets. Utilize workforce metrics to monitor, identify, and respond to workforce trends. Timely completion of employee performance appraisals. Conduct regular meetings, inform team of changes in policy or procedure, and provide information regarding overall strategy and direction of the health plan. Mentor, coach, and support direct reports with building teamwork, professional development, and education to achieve optimal performance and develop talent. Ensure employee engagement survey participation rates and results meet established targets. Mandatory requirements are completed timely by employees. Required licensure, certification, and/or registry are current and in good standing for all employees. Employee performance is monitored and managed. Consult with the Office of Talent Management as appropriate regarding employee performance concerns and disciplinary action.

               

Professional Accountability

Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines. Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements. Attends required meetings and town halls. Recognizes and communicate ethical and legal concerns through the established channels of communication. Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. Maintains confidentiality at all times. Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

 

Job Accountabilities

Identifies and analyzes the design of jobs, work processes, workflows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

 

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.