Director of Claims (Medical Claims)

San Antonio - USA

Monthly Salary: Not Disclosed

Posted on: 27-09-2025

Vacancies: 1 Vacancy

Job Summary

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 of HealthTexas while upholding our Mission Vision and Values.

Culture and Values Expectations

At HealthTexas we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive collaborative and innovative environment where every Associate feels valued empowered and motivated to reach their full potential. Our culture is the driving force behind our mission to deliver quality and compassionate care with outstanding service every patient every time. As a (Job Title) at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.

Integrity: Do the right thing the right way every time.
- Be honest and uphold commitments and responsibilities earn the trust and respect of the team and those we serve and maintain privacy and confidentiality.
Compassion: Treat everyone with respect and dignity.
- Foster an environment of inclusivity and well-being practice patience and empathy and assume positive intent.
Synergy: Collaborate to improve outcomes.
- Invite and explore new opportunities promote effective communication and teamwork take pride in yourself your work and HealthTexas.
Stewardship: Use resources responsibly and efficiently.
- Implement effective strategies to attain goals achieve maximum productivity and results and seek continuous knowledge and improvement.

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.
Other duties as assigned.

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

Bachelors Degree in a related field is 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 HMOs and PPOs.
Knowledge of patient privacy and maintains confidentiality of all sensitive information.

Work Hours Travel Requirements

Monday Friday 8:00 a.m. 5:00 p.m. and as needed to complete projects.
Travel to medical offices may be necessary for the purpose of providing benefit education.

Working Conditions & Physical Requirements

This job operates in an office setting. This role routinely uses standard office equipment such as computers phones photocopiers scanners filing cabinets and fax machines.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job the employee is regularly required to talk and hear. This is largely a sedentary role; however some filing is required. This would require the ability to lift files open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and ability to adjust focus.l

Required Experience:

Director

Job PurposeThe 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 wit...

Job Purpose

Culture and Values Expectations

Integrity: Do the right thing the right way every time.
- Be honest and uphold commitments and responsibilities earn the trust and respect of the team and those we serve and maintain privacy and confidentiality.
Compassion: Treat everyone with respect and dignity.
- Foster an environment of inclusivity and well-being practice patience and empathy and assume positive intent.
Synergy: Collaborate to improve outcomes.
- Invite and explore new opportunities promote effective communication and teamwork take pride in yourself your work and HealthTexas.
Stewardship: Use resources responsibly and efficiently.
- Implement effective strategies to attain goals achieve maximum productivity and results and seek continuous knowledge and improvement.

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.
Other duties as assigned.

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

Bachelors Degree in a related field is 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 HMOs and PPOs.
Knowledge of patient privacy and maintains confidentiality of all sensitive information.

Work Hours Travel Requirements

Monday Friday 8:00 a.m. 5:00 p.m. and as needed to complete projects.
Travel to medical offices may be necessary for the purpose of providing benefit education.

Working Conditions & Physical Requirements

This job operates in an office setting. This role routinely uses standard office equipment such as computers phones photocopiers scanners filing cabinets and fax machines.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job the employee is regularly required to talk and hear. This is largely a sedentary role; however some filing is required. This would require the ability to lift files open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and ability to adjust focus.l

Required Experience:

Director

Key Skills

Corporate Paralegal
Baan
IT Sales and Marketing
Civil Quality Control
Activex
Jboss

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About Company

HealthTexas

Events Saturday Care Patient Education Vitamins Share Your Thoughts Insurances We Accept Questions on Medicare Options & Benefits 210.731.4864. Become a New Patient Get Started Existing Patient Patient Portal Our Practice Learn More Personal Healthcare for all your stages of life. Wit ... View more

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