Commonwealth Care Alliance Job Details: Director, Claims Operations in Boston, Massachusetts

Job Details: Director, Claims Operations

On-Line Application

  • Vacancy NoVN1661

Posting TitleDirector, Claims Operations

Location CityBoston

Language Requirement

Job Description

The Director of Healthcare Claims Operations is a leader on the operations team, reporting directly to the Vice President of Claims and Provider Network Operations.

The Director of Claims Operations is responsible for healthcare claims strategy and operations, development and execution of department efficiencies, management of claims vendor, compliance with all applicable state/federal regulations as well as service level agreements and performance guarantees, strategies to enhance approval rates and electronic submissions, and oversight of day-to-day operations including claims processing. The director works closely with the network, clinical and IT departments to execute on improving performance of the department.


  • Develops and leads strategies for designing and improving robust claims operations platforms serving complex dually eligible Medicare and Medicaid populations.

  • Provides direct oversight of the Claims staff.

  • Oversight of healthcare claims processing, ensuring accurate and timely payment to providers.

  • Represents Commonwealth Care Alliance in all client claims matters.

  • Leads strategies to enhance electronic transactions with internal and external customers and stakeholders.

  • Leads implementation of complex payment methodologies.

  • Manages claims processing and payment disbursement vendor, ensuring vendors are accountable to contract requirements, statement of work, and meeting/exceeding service level requirements.

  • Monitors claims approval rates and develops strategies to improve approval rates in conjunction with the Network leadership.

  • Ensures compliance with all client Service Level Agreements and Performance Guarantees.

  • Ensures compliance with all healthcare claims related contractual and regulatory requirements, including HIPAA, Mental Health Parity, prompt pay and all managed care laws.

  • Analysis of claim payments and denials to identify and address trends and opportunities for provider education.

  • Serves as HIPAA compliant coding expert.

  • This position manages all employees of the department and is responsible for the performance management and hiring of the employees within that department.


  • Relevant Bachelor’s degree (Business, Healthcare or similar), or equivalent combination of education and experience.

  • At least Five (5) years of experience in oversight of claims operations, preferably with expertise in both public and commercial claims processing.

  • Expertise in Medicaid and Medicare claims regulations and coding preferred.

  • Supervisory experience required.

  • Vendor management experience preferred.

  • Certified coder preferred but not required.

  • Business process engineering experience preferred.

  • 5+ years of processing claims, preferably Medicaid and/or Medicare claims.

  • Experience in claims auditing/quality assurance role.

  • Solid understanding of CPT and ICD coding requirements. Coding certification preferred.

  • Knowledge of Third Party Liability and Fraud Waste and Abuse issues.

Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.