Director I Claims

Anticipated End Date:

Position Title:

Job Description:

Location: Tampa FL

Hours: Standard Working hours

Travel: This role requires associates to be in-office 3 days per week fostering collaboration and connectivity while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment unless an accommodation is granted as required by law.

Position Overview:

Leads a large complex Government Claims operation with end-to-end accountability across Medicare and Medicaid first-time claims post-pay claims provider inquiries and correspondence and claim adjustment and sweep activity. This role is accountable for accurate and timely claim outcomes regulatory and contractual compliance audit readiness service-level performance and sustained operational improvement. The Director translates deep government program and claims expertise into disciplined execution strong controls effective issue resolution and measurable improvements in efficiency and capacity. The role also serves as an operational leader for improving claims automation capabilities strongly supporting or taking point on the development and execution of initiatives that materially improve claims performance while maintaining quality compliance and customer experience.

How You Will Make an Impact:

• Providing a broad range of services needed by policy owners/clients and filed force to maintain in-force policies or new business
• Develops/implements complaint resolution procedures
• Develops short/long-term customer service objectives and continuously monitors procedures to ensure these are met by staff
• Ensures area is staffed and trained to handle inquiries from agents and policy owners
• Stays abreast of state and federal regulations and their impact on the industry
• Hires trains coaches counsels and evaluates performance of direct reports
• Provide strategic and operational leadership across Medicare and Medicaid claims including first-time claim processing post-pay adjustments corrected claims provider inquiries written correspondence escalations and mass-adjustment or sweep activity.
• Establish and maintain a management system that consistently meets or exceeds service-level agreements prompt-pay requirements performance guarantees quality standards inventory targets and regulatory commitments.
• Use deep knowledge of Medicare and Medicaid policies state and federal requirements benefit and reimbursement rules claims platforms and operational workflows to guide complex claim decisions and resolve systemic issues.
• Own audit readiness and response for the assigned operation including control design evidence production issue remediation corrective action planning and sustained monitoring of regulatory client internal and external audit findings.
• Partner closely with technology digital analytics payment integrity provider operations finance compliance audit market and vendor teams to deliver integrated solutions and remove barriers to operational performance.
• Build and maintain performance visibility through actionable metrics trend analysis capacity and demand planning risk indicators and executive-level reporting that clearly identifies drivers decisions and corrective actions.
• Ensure staffing workflow allocation training documentation and leadership routines are sufficient to manage changing volumes regulatory requirements and business priorities without compromising service or quality.
• Lead develop and hold accountable a multi-level organization; strengthen succession and talent pipelines while creating a culture of ownership continuous improvement regulatory discipline and customer focus.

Required Qualifications:

• Requires a BA/BS and 7 years leadership experience; or any combination of education and experience which would provide an equivalent background.

Preferred Qualifications:

• Extensive leadership experience in health plan claims operations with direct responsibility for both Medicare and Medicaid lines of business.
• Demonstrated experience leading or serving as the operational point person for a claims automation initiative with measured impact to efficiency productivity capacity quality cost or cycle time.
• Experience developing business requirements partnering with technology and digital teams supporting testing and implementation managing operational readiness and adoption and validating post-implementation benefits.
• Executive-level communication and cross-functional influence skills with the ability to translate complex regulatory and operational issues into clear decisions actions and accountability.

Job Level:

Workshift:

Job Family:

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes including those submitted to hiring managers are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy power our business outcomes and drive our shared success - for our consumers our associates our communities and our business.

We offer a range of market-competitive total rewards that include merit increases paid holidays Paid Time Off and incentive bonus programs (unless covered by a collective bargaining agreement) medical dental vision short and long term disability benefits 401(k) match stock purchase plan life insurance wellness programs and financial education resources to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager associates are required to work at an Elevance Health location at least once per week and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age citizenship status color creed disability ethnicity genetic information gender (including gender identity and gender expression) marital status national origin race religion sex sexual orientation veteran status or any other status or condition protected by applicable federal state or local laws. Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws including but not limited to the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13 the posting will automatically come down on 3/12 at 11:59:59 other words the job is posted until 3/13 not through 3/13.