Director, Claims Operations

Oversee claims adjudication, payment integrity, and claims processing workflows.

Ensure compliance with contractual obligations, health plan requirements, reimbursement methodologies, and applicable federal and state regulations.

Develop and maintain policies, procedures, and operational standards supporting compliant claims administration.

Monitor quality assurance programs and claims audit activities to identify risks and drive corrective actions.

Investigate and resolve escalated claims issues and operational concerns.

Partner with Compliance and Legal teams to support regulatory readiness and audit responses.

Provide leadership and oversight for encounter submission, reconciliation, monitoring, and issue resolution processes.

Ensure encounter data is submitted accurately and timely according to health plan requirements.

Collaborate with operational and technical teams to resolve encounter rejections, discrepancies, and process defects.

Establish controls and reporting mechanisms that support data integrity and regulatory compliance.

Drive ongoing enhancements to encounter processes that improve efficiency and transparency.

Partner with Technology and business stakeholders to optimize claims systems, workflows, and operational tools.

Oversee claims configuration, testing, implementation support, and enhancement initiatives.

Identify opportunities to automate manual processes and improve operational scalability.

Monitor system performance and work proactively to resolve operational barriers.

Support implementation of new technologies that enhance productivity, reporting, accuracy, and service delivery.

Manage relationships with third-party vendors and external partners supporting claims operations.

Collaborate with health plans and stakeholders to address operational concerns, service level expectations, and compliance requirements.

Participate in business reviews and operational performance discussions with clients and partners.

Ensure vendor performance aligns with contractual and operational expectations.

Establish and monitor key performance indicators (KPIs) related to claims inventory, turnaround times, payment accuracy, encounter acceptance rates, productivity, quality, and compliance.

Analyze operational trends and identify opportunities to improve performance and reduce risk.

Develop and present operational reporting and performance insights to executive leadership.

Lead initiatives that improve department efficiency, reduce errors, and enhance overall service levels.

Maintain accountability for meeting organizational and departmental performance objectives.

Partner with Finance on claims reconciliation, financial reporting, and operational alignment activities.

Collaborate with Network Operations, Provider Relations, Compliance, Technology, and other departments to improve business outcomes.

Support organizational growth initiatives, operational projects, and strategic priorities.

Serve as a trusted advisor and subject matter expert on claims operations and industry best practices.

Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field required.

Master's degree preferred.

Equivalent combination of education and experience may be considered.

7+ years of healthcare claims operations experience, preferably within managed care, payer, Medicare, Medicaid, or health plan environments.

3+ years of leadership experience managing claims teams and operational performance.

Demonstrated success overseeing claims adjudication, payment integrity, encounter operations, and compliance initiatives.

Experience leading operational improvement projects and technology-enabled process enhancements.

Proven ability to effectively manage cross-functional relationships and operational priorities in a fast-paced environment.

Strong understanding of healthcare claims processing, reimbursement methodologies, provider contracts, and payment integrity practices.

Knowledge of encounter submission processes, EDI transactions, claims data workflows, and regulatory requirements.

Experience with claims management systems, reporting tools, and operational analytics.

Ability to interpret performance data and translate findings into actionable business solutions.

Proficiency with Microsoft Office Suite and operational reporting platforms.

Strategic and operational leadership

Performance management and team development

Process improvement and operational excellence

Change management

Stakeholder and relationship management

Decision-making and problem-solving

Data-driven business acumen

Effective communication and presentation skills

Collaboration and influence across all levels of the organization

Claims payment accuracy

Claims inventory management and turnaround times

Encounter acceptance and reconciliation performance

Compliance and audit outcomes

Department productivity and quality metrics

Employee engagement and retention

Process improvement initiatives and operational efficiencies

Health plan and stakeholder satisfaction

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.