Director of Claims
hace 9 días
Phoenix
Job Description:\n\n ABOUT ADOBE \n Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 with a mission of positively impacting the lives we touch. Headquartered in Phoenix, AZ, with satellite locations across multiple states, APH fosters a culture rooted in inclusivity, human kindness, and high-quality care. \n Recognized by Inc. 5000 as one of America’s Fastest-Growing Private Companies and honored for a fifth consecutive year as a “Best Place to Work” by the Phoenix Business Journal, APH continues to expand its reach and impact. \n APH partners with health plans, providers, hospitals, and families to deliver tailored programs including case management, in-home and in-clinic wellness assessments, preventative care, transitional care, and social services. As one of the nation’s few fully integrated healthcare organizations, APH delivers comprehensive, coordinated medical and social support through a wide range of specialized service lines. \n With continued growth on the horizon, APH is seeking mission-driven individuals who are passionate about improving health outcomes and supporting those in need. \n \n POSITION PURPOSE\n The Director of Claims provides strategic and operational leadership for the organization’s claims lifecycle, ensuring accurate, timely, and compliant claims submission, adjudication, payment, reconciliation, and collection. This role is responsible for managing claims inventory, reducing denials and underpayments, resolving payer disputes, minimizing revenue leakage, and improving reimbursement performance across the organization’s payer portfolio.\n Working collaboratively with all relevant departments of the organization, the Director of Claims establishes standardized billing procedures, monitors payer requirements, validates billing readiness, and implements processes that support accurate reimbursement and sustainable revenue cycle performance.\n The ideal candidate combines strong claims expertise with analytical problem-solving, cross-functional leadership, and a continuous improvement mindset. This individual will translate claims data into actionable strategies, establish clear accountability, and build scalable processes that support organizational growth and the delivery of high-quality population health services.\n This position supports business operations while leveraging data analytics, process improvement, and technology to drive operational excellence, revenue integrity, and exceptional customer service. The position is located at the Phoenix office (near SR-51, Glendale Avenue, and 16th Street) and requires working in the office five days per week. \n \n DUTIES & RESPONSIBILITIES\n Claims Operations & Inventory Management\n \n Oversee the end-to-end claims lifecycle, including claims preparation, submission, adjudication, payment, reconciliation, correction, resubmission, and collection.\n Manage claims inventory to ensure timely processing, appropriate prioritization, and resolution of outstanding claims.\n Establish and maintain standardized workflows for claims submission, rejection management, denial resolution, appeals, and resubmissions.\n Monitor claims aging, identify high-risk and high-value outstanding balances, and implement targeted collection action plans.\n Ensure claims-related eligibility denials are appropriately investigated, documented, communicated to relevant stakeholders, and resolved when possible.\n Establish procedures for tracking unresolved claims, payer responses, required documentation, filing deadlines, and follow-up activities.\n Oversee claims billing procedures and maintain clear documentation of workflows, responsibilities, escalation pathways, and performance expectations.\n \n Claims Submission, Rejections & Denial Management\n \n Ensure claims are submitted accurately and within applicable payer and contractual filing deadlines.\n Monitor rejected and denied claims, identify root causes, and implement corrective actions to reduce preventable rework and reimbursement delays.\n Oversee claim corrections, appeals, reconsiderations, and resubmissions, ensuring compliance with payer requirements and established timelines.\n Analyze denial trends by payer, service type, eligibility status, coding or billing issue, authorization requirement, documentation deficiency, and other relevant factors.\n Partner with Clinical Operations, providers, coding and billing teams, and other stakeholders to resolve issues affecting claim acceptance and payment.\n Develop and maintain denial prevention strategies, including staff education, workflow improvements, and appropriate system edits.\n Ensure denials and appeals are documented consistently and that recoverable revenue is pursued within applicable deadlines.\n \n Payer Follow-Up, Collections & Revenue Recovery\n \n Lead payer follow-up activities to resolve unpaid, delayed, rejected, underpaid, and disputed claims.\n Establish collection strategies based on claim aging, outstanding balances, payer behavior, contractual obligations, and likelihood of recovery.\n Oversee collection of outstanding claims revenue and ensure timely escalation of unresolved payer issues.\n Identify claims underpayments by comparing actual reimbursement with applicable contractual rates, fee schedules, payment terms, and reimbursement methodologies.\n Lead the investigation and resolution of underpayments, payment discrepancies, and payer contractual collection disputes.\n Monitor payer response times, payment trends, unresolved balances, and recurring reimbursement issues.\n Collaborate with Finance to reconcile claims activity, payment records, remittances, accounts receivable, and expected revenue.\n Identify revenue leakage, missed billing opportunities, preventable write-offs, and other reimbursement gaps; develop and monitor corrective action plans.\n Escalate material or recurring payer disputes to appropriate leadership and Contracting partners, providing supporting data and recommended actions.\n \n Billing Readiness & Contract Implementation\n \n Partner with Contracting, Finance, Clinical Operations, and IT to ensure new and amended payer contracts are operationally ready for billing before implementation.\n Translate contractual reimbursement requirements, covered services, billing rules, effective dates, provider requirements, and submission procedures into documented operational workflows.\n Validate billing readiness for new services, programs, providers, locations, payer arrangements, and contract changes.\n Establish readiness checkpoints to confirm required systems, payer configurations, provider enrollment or credentialing requirements, eligibility processes, documentation standards, and billing rules are in place, as applicable.\n Oversee claims testing and payer adjudication validation to confirm that claims process according to expected billing rules and contractual reimbursement terms.\n Investigate discrepancies between expected and actual claim adjudication and coordinate resolution with internal teams and payer representatives.\n Maintain documentation of billing requirements, payer-specific procedures, testing outcomes, known issues, and implementation approvals.\n Proactively identify implementation risks that could delay billing, prevent claim acceptance, or negatively affect reimbursement.\n \n Payment, Remittance & Reconciliation Accuracy\n \n Oversee claims payment accuracy and ensure appropriate reconciliation of expected reimbursement, actual payments, adjustments, denials, and outstanding balances.\n Monitor the ingestion, processing, and reconciliation of Electronic Remittance Advice (ERA).\n Partner with IT, Finance, and billing system stakeholders to resolve 835 ingestion failures, mapping issues, posting discrepancies, and other remittance-processing exceptions.\n Ensure remittance data is accurately reflected in relevant billing, claims, and financial systems.\n Establish controls to identify unapplied payments, duplicate payments, incorrect adjustments, unexplained variances, and other payment discrepancies.\n Support accurate financial reporting by maintaining reliable claims status, payment, adjustment, and collection data.\n Coordinate investigations of recurring payment or reconciliation errors and implement sustainable corrective actions.\n \n Performance Management, Reporting & Continuous Improvement\n \n Establish, monitor, and report on claims key performance indicators (KPIs), including:\n \n Claims submission volume and timeliness.\n First-pass acceptance and clean-claim rates.\n Claim rejection and denial rates.\n Denial overturn and appeal success rates.\n Days in accounts receivable and claims aging distribution.\n Outstanding claims inventory and collection performance.\n Underpayment identification and recovery.\n Net collection and reimbursement accuracy.\n Preventable write-offs and identified revenue leakage.\n Payer turnaround times and unresolved claim balances.\n Billing readiness and claims testing outcomes.\n \n Develop dashboards, reports, and executive summaries that communicate performance trends, root causes, financial exposure, and recommended actions.\n Establish measurable performance goals and accountability for claims resolution, follow-up, collections, and process compliance.\n Use data analysis to identify recurring operational barriers and prioritize improvement initiatives based on financial impact, urgency, and recoverability.\n Evaluate claims workflows, systems, automation opportunities, and controls to improve accuracy, efficiency, scalability, and visibility.\n Maintain effective escalation processes for aging inventory, high-value claims, systemic payer issues, and material reimbursement risks.\n \n Leadership & Cross-Functional Collaboration\n \n Lead, develop, and support claims and revenue cycle personnel through clear expectations, coaching, performance management, and professional development.\n Establish consistent procedures, quality standards, and training to promote accuracy, accountability, and timely claims resolution.\n Partner with Finance, Contracting, Clinical Operations, Quality, Compliance, IT, and executive leadership to address claims-related barriers and improve organizational performance.\n Communicate material claims risks, collection challenges, payer disputes, reimbursement trends, and improvement opportunities to leadership.\n Foster a collaborative, inclusive, and solutions-oriented team culture that encourages continuous learning, respectful communication, and shared accountability.\n Support organizational growth by developing scalable claims processes and ensuring new services and payer arrangements are prepared for effective billing and reimbursement.\n \n Compliance, Controls & Documentation\n \n Ensure claims operations follow applicable federal and state requirements, payer policies, contractual obligations, timely filing rules, and organizational procedures.\n Partner with Compliance and other designated stakeholders to maintain appropriate documentation, audit readiness, and internal controls.\n Promote appropriate handling of protected health information and compliance with HIPAA and applicable privacy and security requirements.\n Maintain clear documentation of claims decisions, appeals, payer communications, collection actions, adjustments, and dispute resolutions.\n Identify and escalate potential billing irregularities, inappropriate payment practices, recurring control failures, or other compliance concerns through established channels.\n Support internal and external audits, payer reviews, and corrective action initiatives as required.\n \n \n SKILLS & QUALIFICATIONS\n \n Seven (7) years of progressive healthcare claims experience. \n Three (3) years of leadership experience managing claims, billing, collections, or reimbursement teams. \n Participate in special projects and organizational initiatives as assigned. \n Demonstrated experience in claims operations, healthcare billing, revenue cycle management, reimbursement, or payer claims administration.\n Strong understanding of claims submission, rejection and denial management, appeals, resubmissions, payer follow-up, collections, and accounts receivable.\n Experience identifying and resolving underpayments, contractual payment discrepancies, aging claims, and revenue leakage.\n Knowledge of payer billing requirements, reimbursement methodologies, contractual terms, and claims filing and appeal deadlines.\n Experience monitoring claims KPIs, analyzing trends, developing action plans, and communicating financial and operational results.\n Demonstrated ability to lead cross-functional initiatives and coordinate effectively with Finance, Contracting, Clinical Operations, IT, and payer representatives.\n Strong analytical and problem-solving skills, including the ability to investigate discrepancies, determine root causes, and implement sustainable solutions.\n Ability to establish standardized procedures, internal controls, escalation pathways, and measurable performance expectations.\n Strong written and verbal communication skills, with the ability to present complex claims and reimbursement issues clearly to technical and nontechnical audiences.\n Demonstrated organizational skills, attention to detail, sound judgment, and the ability to manage competing priorities.\n Ability to lead teams with professionalism, fairness, accountability, and respect for diverse perspectives.\n Proficiency with claims management, billing, accounts receivable, reporting, and spreadsheet applications.\n Ability to handle confidential information appropriately and maintain compliance with applicable privacy and security requirements.\n Experience in population health, value-based care, managed care, provider services, community-based healthcare, or other healthcare service delivery environments.\n Experience managing claims across multiple payers, states, programs, service lines, or reimbursement models.\n Familiarity with Medicaid, Medicare, Medicare Advantage, commercial payer arrangements, and applicable claims requirements.\n Experience with Electronic Data Interchange (EDI), particularly the X12 837 claims transaction and X12 835 remittance advice transaction.\n Experience with automated claims edits, payment posting, electronic remittance processing, denial analytics, and revenue cycle reporting.\n Experience supporting payer contract implementation, fee schedule validation, reimbursement testing, and operational billing readiness.\n Experience working with electronic health records, practice management platforms, claims clearinghouses, and financial or enterprise reporting systems.\n Experience leading process improvement, system implementation, workflow standardization, or revenue recovery initiatives.\n Demonstrated success improving clean-claim rates, reducing denials and aging inventory, increasing collections, or recovering underpaid claims
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