Claims and Payments Director

A company is looking for a Claims & Payments Director.

Key Responsibilities

Interface directly with providers on claims policies and disputes

Lead the Payment Policy Committee and provide policy recommendations

Review provider contracts for compliance and operational feasibility

Make adjudication decisions on complex claims and set policy precedents

Required Qualifications

10+ years of deep claims expertise in U.S. healthcare and Medicare Advantage

Mastery of claims policy from extensive experience at a large-scale payer

Strong functional expertise in Medicare Advantage health plan operations

Deep knowledge of medical coding (CPT, HCPCS Level II, ICD-10-CM / PCS) is a plus

Proficiency with technology and AI tools for claims and policy research