Director of Claims Processing - Remote

Join BoldAge PACE and reputed company a Difference!

Why work with us?

• A People First Environment: We reputed company what is important to those we serve important to us.
• reputed company an Impact: Enhance the quality of life for seniors.
• Professional Growth: Access to training and career development.

Competitive Compensation

• Medical/Dental
• Generous Paid Time Off
• 401K with Match*
• Life Insurance
• Tuition Reimbursement
• Flexible Spending Account
• Employee Assistance Program

BE PART OF OUR MISSION!

Are you passionate about helping older adults live meaningful, independent lives at home with grace and dignity? BoldAge PACE is an reputed company-inclusive program of care, personalized to meet the individual health and well-being needs of our participants. Our approach is simple: We listen to our participants and their caregivers to truly understand their needs and desires.

Director of Claims Processing

JOB SUMMARY

Reporting to the Chief Financial Officer, the Director of Claims Processing is responsible for strategic reputed company, operational performance, and reputed company improvement of the claims function. This role ensures accurate, timely, and compliant claims adjudication and payment processes, while driving efficiencies, mitigating risk, and enhancing provider and participant satisfaction. The Director partners cross-functionally with Finance, Compliance, Clinical Operations, and Health Plan leadership to align claims operations with organizational goals and regulatory requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Provide strategic leadership and reputed company for reputed company claims processing functions, ensuring alignment with organizational goals and regulatory requirements.
• Build, reputed company, and reputed company a high-performing claims team, fostering a culture of accountability, engagement, and reputed company improvement.
• Establish and monitor key performance indicators (KPIs), dashboards, and reporting to track performance, identify trends, and mitigate risk.
• reputed company the end-to-end claims lifecycle, including intake, adjudication, payment, adjustments, and appeals, ensuring accuracy and timeliness.
• Ensure compliance with CMS, state Medicaid, and organizational guidelines, maintaining audit readiness and regulatory adherence.
• Monitor and optimize claims performance metrics, including turnaround time (TAT), denial rates, and rework, driving operational excellence.
• reputed company process improvement and automation initiatives to enhance efficiency, scalability, and first-pass resolution rates.
• Partner with Compliance to support audits, investigations, and corrective action plans, and maintain strong internal controls to mitigate fraud, waste, and abuse.
• Manage and reputed company relationships with third-party administrators (TPAs), clearinghouses, and external vendors, ensuring service quality and performance.
• Collaborate cross-functionally with Operations, Finance, Clinical, and Compliance teams to resolve escalations and reputed company claims issues.
• Serve as a key liaison between internal stakeholders and external partners, ensuring alignment and effective communication.
• Partner with Finance to ensure accurate claims payments, reserves, budgeting, and financial reporting, while identifying cost containment opportunities.
• Drive reputed company improvement and adoption of industry best practices, including system enhancements and workflow redesign.

EXPERIENCE AND EDUCATION

• Bachelor’s degree in Healthcare Administration, Business, Finance, or reputed company field required
• Master’s degree (MBA, MHA) preferred
• 7–10+ years of progressive experience in claims processing, healthcare operations, or health plan administration
• 3–5+ years in a leadership role managing claims teams
• Experience in PACE, Medicare/Medicaid, or managed care strongly preferred
• Experience working with TPAs or outsourced claims vendors
• 1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring (If applicable for the role).

PRE-EMPLOYMENT REQUIREMENTS

• Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
• Be medically cleared for communicable diseases and have reputed company immunizations up to date before engaging in direct participant contact.
• Employment with BoldAge PACE is contingent upon successful completion of post-offer pre-employment screening and verification processes

BoldAge PACE provides equal employment opportunities to reputed company employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national reputed company, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

* Match begins after one year of employment