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Director, TPA Claims and Systems

Director, TPA Claims and Systems

Job Locations 
US-VA-Glen Allen
Job ID 

Job Description


The Director of Claims and Systems is an executive management position responsible for planning, implementing and controlling claim strategies that will ensure high quality, timely, and efficient claim service throughout the operation with emphasis on claim configuration, systems, e-service, and encounters. 


  • Ensures Managers are effectively monitoring and tracking claim metrics to meet customer service levels and/or government program standards
  • Participates in client leadership meetings with responsibilities of both presenting TPA Claims outcomes and obtaining business needs, advising client on information technology strategy & solutions provided as part of TPA contracted services.
  • Direct oversight of configuration activities to ensure timely & accurate payment in accordance with government program standards and client contracts.
  • Direct TPA encounter team to ensure timely and accurate submission of encounter data to state agencies.
  • Work closely with TPA claims production and customer service to ensure claims configuration changes and issues are openly communicated and/or addressed.
  • Provides oversight and vision to the creation or modification of departmental policies and procedures, process maps, and metrics.
  • Leads research and development of new technology as it pertains to claims administration
  • Make recommendations regarding continuous improvement of claims department,    work processes and operating procedures
  • Monitors and tracks staff performance relating to service level agreements and departmental standards
  • Demonstrates successful leadership in selecting, developing, motivating and directing a highly effective team, which includes mentoring, training and providing guidance to ensure continual growth of management staff
  • Works with enterprise-wide change management approaches; manages up, down and across the organization to accomplish short term and long term goals. 
  • Facilitates change by addressing points of resistance and individual issues or concerns.  Acts as a facilitator to help remove barriers and satisfy customer requirements.
  • Other duties as assigned



  • Bachelors Degree in Business Administration, Health Care or Other related field
  • Advanced Degree desired, but not required


  • Minimum 3-5 years management experience in a Claims Department or related field
  • Minimum 2-4 years of vendor relationship experience
  • Experience with large scale system conversion projects
  • In depth knowledge of CPT, ICD.9 and HCPC coding guidelines
  • QNXT System experience preferred, but not required
  • Advanced knowledge of claim benchmarks and related metrics
  • Proven analytical skills, project management and strategic planning with an emphasis on process improvement
  • Knowledge and/or experience implementing Six Sigma processes a plus
  • Experience managing claims administration for governmental programs such as Medicare and/or Medicaid


Physical health sufficient to meet the ergonomic standards and demands of the position.



About Us

Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!

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