• Senior Director, Health Claims Processing Operations

    Job Locations US-VA-Glen Allen
    Job ID
  • Overview

    The Senior Director of Health Claims Operations will be responsible for all operational Claims processing oversight for all lines of business within Virginia Premier.  This includes monitoring daily claims production and volumes within all claim processing units, comparing the results to the Centers for Medicare and Medicaid Services (CMS) and the Department of Medical Assistance Services (DMAS) benefits and adjudication standards to ensure claims are processed according to federal, state and individual contractual regulatory policies and guidelines.  Will also work closely with Virginia Premier’s program directors, compliance leadership and program integrity departments to ensure all programs are administered appropriately.  





    • Using information generated by CMS and DMAS to research, review, create and document policies and procedures necessary to insure Virginia Premier adheres to Federal and state guidelines for claims processing and provider interaction. This includes, but is not limited to, tracking changes in reimbursement, coverage policies, legislation that affect claims adjudication and/or provider communications.
    • Create Medicare/Medicaid operational and claims processing policies, standard operating procedures, process maps, and metrics
    • Ensure claims departmental units are aware of the program statuses, modification and system requirements
    • Assist with the claims processing system design, development, set-up and maintenance of all Virginia Premier’s lines of business.
    • Help facilitate difficult Medicare/Medicaid claim issues, correspondence or telephone calls as directed by staff, management and/or claim processing vendor.
    • Assist other Claims Operational Directors/Managers in the development and updating of department policies and procedures related all VPHP’s lines of business.
    • Ensure the compliance in all areas of operations such as accurate and timely processing of claims
    • Oversee the development and improvements of claims related projects to ensure additional compliance and accuracy
    • Review current workflows/procedures to identify process gaps and develop opportunities to mitigate this gaps
    • Use data/analytics to illuminate root cause issues and develop solutions which are innovative and can result in saving, improved quality and increased efficiency
    • Build System quality metrics to monitor and mitigate claims payment accuracy
    • Work with configuration and operational departments that contributes to the reimbursement of the claims




    • Bachelor’s Degree Required in Business Administration, Health Care or other related field
    • Master’s Degree Preferred


    • Extensive knowledge of Medicare (Parts A, B & C) and Medicaid programs
    • Knowledge of CPT-4 and ICD-10 coding; understanding of Medicare’s Correct Coding Initiative (CCI)
    • Proven analytical skills, project management and strategic planning with an emphasis on process improvement
    • Knowledge of various software packages (Microsoft Office)
    • Self-motivated with an appreciation for a fast paced environment
    • Detail oriented
    • Excellent written and verbal skills
    • Superior time management skills


    • Minimum of 3 years experience with CMS and DMAS state regulatory guidelines related to claims processing and other Federal/state requirements
    • Three (3) years managerial level supervisory experience 
    • TriZetto QNXT Platform knowledge preferred
    • Knowledge of Lean Six Sigma methodology preferred, but not required
    • Proven 7-10 years Medicare/Medicaid operational, compliance and/or regulatory experience with CMS and/or state regulatory agencies
    • Proven project management experience



    • 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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