• Senior Director, Health Claims Customer Service Operations

    Job Locations US-VA-Glen Allen
    Job ID
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
    If this sounds like you, read on!


    The Senior Director of Health Claims Customer Service Operations will assume all operational responsibility and oversight for all lines of business within Virginia Premier.  This includes monitoring daily incoming calls, portal inquiries, and any claims adjudication performed by the Customer Service team.  Incumbent will ensure the Customer Service unit meets contractual metrics for Centers for Medicare and Medicaid Services (CMS) and the Department of Medical Assistance Services (DMAS). Will ensure the team has adequate tools and training of each lines of business to ensure claims are processing according to federal, state and individual contractual regulatory policies and guidelines.  Will also be responsible for the creation or aligning of operation units to efficiently support the call center demands by ensuring the team has policies, standard operating procedures, process maps, metrics, etc.  Will work closely with Virginia Premier’s program directors, compliance leadership and program integrity departments to ensure all programs are administered appropriately.  This individual will also work with the entire internal claim departmental units to ensure areas are aware of the program statuses, modifications, system requirements, etc.



    • 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.
    • Using demonstrated knowledge of Medicare and Medicaid reimbursement methodologies, federal and state regulations and policies to assist in the claim processing system design and training, 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.
    • Responsible for hiring staff and conducting employee evaluations.
    • Evaluate training needs, help develop programs to meet those needs; act as mentor/coach.
    • Continuously monitor current workloads and make adjustments when appropriate to meet department goals.
    • Assist other Claims Operational Directors/Managers in the development and updating of department policies and procedures related all Virginia Premier lines of business.
    • Ensure compliance in all areas of operations such as accurate and timely processing of claims
    • Oversee the development and improvements of the Claims Refund department 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



    • 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
    • Extensive experience in operating a Claims Customer Service department
    • Familiar with Centers for Medicare and Medicaid Services (CMS) and state regulatory guidelines related to claim processing and other Federal/state requirements
    • Knowledge of CPT-4 and ICD-10 coding; understanding of Medicare’s Correct Coding Initiative (CCI)
    • 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


    • Proven analytical skills, project management and strategic planning with an emphasis on process improvement
    • 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


    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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