Director of Claims & Enrollment

We are recruiting for a mission-driven Director of Claims & Enrollment to join our team!
We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey.
Our Values
Respect | Belonging | Accountability | Transparency
Department
Managed Care Administration
Job Summary
As the Director of Claims and Enrollment, you will lead the daily operational management of claims, enrollment, and credentialing while also providing strategic oversight of encounters and system configuration functions. Primary accountability centers on keeping daily operations running accurately and in compliance, while simultaneously solving problems and driving continuous improvement across all areas. Encounters is a recurring weekly and monthly process where this role provides oversight and works to improve rejection rates and submission outcomes. System configuration is not an operational function but rather a strategic one, focused on driving improved claims processing configuration as well as managing seasonal and annual benefits configuration changes. You will provide direct oversight of four internal teams as well as vendor partners whose work supports a significant portion of the organization's operations. Managing vendor relationships in this role is the equivalent of overseeing dozens of additional resources, making vendor oversight a core and critical accountability. By leveraging your expertise, you will drive effective stakeholder communication, streamline issue resolution, ensure regulatory and contractual compliance, and introduce innovative solutions to enhance operational efficiency.
This position requires a leader who can keep daily operations on track while identifying and solving problems across claims, enrollment, credentialing, encounters, and system configuration. Success in this role means maintaining compliance and operational integrity today while building toward a stronger, more efficient organization tomorrow.
Essential Functions:
Claims, Enrollment, Credentialing and Configuration Operations Management
• Oversee and manage the daily operations of claims, enrollment, and credentialing as the primary operational functions of this role. Adheres to and enforces the rules, regulations, and contractual requirements of CMS, CO Medicaid, CO Division of Insurance, contracted and non-contracted providers.
• Oversees the encounters submission process on a weekly and monthly basis, providing direction and driving improvements to rejection rates and acceptance outcomes through vendor oversight and process refinement. System configuration oversight is focused not on daily operations but on driving improved claims processing configuration and managing the seasonal and annual benefits configuration changes that directly impact claims adjudication accuracy.
• Approaches all areas with a problem solving mindset, balancing the need to keep operations running smoothly with the ongoing work of identifying and implementing meaningful improvements.
Manage vendor oversight program of outsourced activities to ensure the contractual performance meet expected outcomes including appropriate turnaround time, accuracy, quality assurance program(s), and issue resolution. To include
• Audit Planning and Execution:
o Lead the planning and execution of audits to assess vendor performance, compliance, and adherence to contractual Service Levels and Key Performance Indicators.
• Conduct thorough risk assessments to identify potential areas for improvement and develop audit programs accordingly.
• Continuous Monitoring:
o Establish and maintain a robust continuous monitoring framework to proactively identify and address emerging risks and issues related to vendor relationships.
o Implement key performance indicators (KPIs) and metrics to measure vendor performance and compliance on an ongoing basis.
o Leverage technology solutions for data analytics, automation, and reporting to enhance the efficiency and effectiveness of vendor auditing processes.
• Issue Resolution and Remediation:
o Lead the resolution of issues identified through audits or other operational escalations, working collaboratively with cross-functional teams to implement corrective and preventive actions.
o Monitor and track the progress of remediation efforts to ensure timely resolution of identified issues.
Stakeholder Communication:
• Regularly communicate audit findings, performance metrics, and risk assessments to senior leadership and key stakeholders.
• Facilitate constructive dialogue with vendors to address concerns, provide feedback, and drive continuous improvement.
(60%)
Compliance and Regulatory Oversight
• Implement operational changes necessary to maintain compliance with regulatory guidance affecting internal teams and external vendors; guarantee the organization's adherence to all applicable laws and regulations.
• Oversee updates and changes to system configuration and team operating procedures to ensure the processing and payment of claims align with Utilization Management policies; collaborate with leadership to promptly address arising issues.
• Collaborate with the Contracting team to verify that claims are processed in accordance with the contract and partner with Provider Relations to resolve any inconsistencies.
• Develop, modify, review, and implement policies and procedures for pricing changes, contractual modifications, and adjustments.
• Monitor and detect potential fraud and abuse, ensuring continuous regulatory compliance across all operations; share findings with Payment Integrity and Compliance teams.
(25%)
Staff Management & Training
• Provides direct oversight of four internal teams as well as the vendors that support a significant portion of the work performed across the organization. The internal teams under this Director’s leadership include Claims, System Configuration, Enrollment, Encounters, and Credentialing. Vendor oversight is equally critical to this role, as managing vendor partners is the equivalent of overseeing dozens of additional resources who execute key operational functions on behalf of the organization.
• Manage the daily operations of the Claims Operations staff, including hiring, training, supervising, evaluating, and developing the Claims and Enrollment Managers.
• Develop, review, and present reports on productivity and accuracy.
• Develop comprehensive training programs and ensure acquisition of knowledge related to all claims policies and procedures. Ensure vendor adherence to same policies and procedures.
(15%)
Education:
Bachelor's Degree required.
Work Experience:
Seven to ten years in a leadership role within claims and enrollment management and oversight, including overseeing benefit configuration, effective process flow implementation, and maintenance for commercial and government product lines required.
Experienced in managing claims processing for Medicare and Medicaid required.
Experience with CHP+, Large Group Commercial, or Healthcare Exchange preferred.
Experience in credentialing operations is preferred.
Knowledge, Skills and Abilities:
Demonstrated track record in creating approaches, policies, and procedures to ensure effectiveness of the claims payment and adjudication process at a health plan.
Solid system development and evaluation abilities, effective leadership and management, and outstanding written and oral communication skills are required.
Experience and proficiency with Trizetto QNXT is highly desired.
Knowledge of Medicare, Medicaid, and commercial fee-for-service schedules, and industry regulations issued by the Center of Medicare and Medicaid Services (“CMS”) and the Colorado Department of Health Care, Policy & Financing (“HCPF”) is required.
Knowledge of all claims forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, Revenue Codes and NDC coding, HIPPA, HEDIS, NCQA.
Knowledge of bundled payments, risk-sharing, and provider capitation is essential.
Proficient with Microsoft Word, Excel, Access, PowerPoint, and claims adjudication systems.
Able to perform effectively in a leadership role and evaluate processes for efficiency.
Experienced in supervising staff and ensuring key tasks and goals are met on a timely basis.
Shift
Days (United States of America)
Work Type
Regular
Salary
$140,000.00 - $231,000.00 / yr
Benefits
At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also o

Skills
Data Analysis, Excel, Auditing, Regulatory Compliance