Director, Claims System and Performance

Provides strategic leadership and direct oversight for Claims Operations Support, Claims Service Operations, and Claims Payment Integrity across VNS Health managed care lines of business. Accountable for driving best-in-class claims processing performance, accurate and timely payments, sustainable operational improvements, and a responsive, transparent provider experience. Establishes performance standards, executive reporting, and cross-functional accountability for claims quality, turnaround, auto-adjudication, payment accuracy, inventory, disputes, and regulatory complaints. Leads payment integrity, recovery, cost avoidance, and audit governance, while building strong internal and external customer relationships. Partners with Claims System Configuration, IT, Compliance, Provider Relations, Network, Finance, Grievances & Appeals, processing vendors, and delegated entities to identify systemic defects, resolve underlying causes, and verify lasting improvements. Contract, benefit, pricing, and technical claims configuration remain outside the position's direct reporting authority. Works under general direction.

Leads senior team members responsible for high-priority claim issue triage, provider escalation support, root-cause research, claims business requirements, operational and executive reporting, user acceptance testing coordination, SOPs, training, and knowledge management.

Directs provider claims dispute and service escalation oversight, DOH complaint investigation support, pended and new-day claims inventory, aging and claims outlier tracking, financial project reporting, and coordinated resolution with Provider Relations, Grievances & Appeals, CCSS, and processing partners.

Leads payment accuracy audits, DFS complaint investigations, recovery and refund activity, MedEx/MCI initiatives, savings and cost avoidance programs, SIU collaboration, and external audit and recovery vendor oversight.

Retains direct ownership of provider contract, rate, pricing, benefit, edit, and technical system configuration. Identifies operational and provider impacts, prioritizes and escalates defects, owns business requirements and validation, and drives closure through accountable configuration and technology partners.

Defines and leads a best-in-class claims performance strategy, establishing baseline and benchmark-informed goals, accountable owners, service-level expectations, and improvement roadmaps by line of business.

Directs performance oversight of internal, external, and delegated claims processing, including timely payment and turnaround, auto-adjudication, first-pass payment accuracy, claims aging, pends, backlog, denials, rework, and unit productivity.

Establishes executive dashboards, service scorecards, operating reviews, and action plans that connect claim-level findings to the provider experience, compliance risk, financial exposure, and measurable operational results.

Sponsors data-driven workflow redesign, controls, automation opportunities, and end-to-end root-cause remediation to reduce payment defects, reprocessing, provider abrasion, and avoidable administrative cost.

Owns the claims-related provider experience improvement agenda, promoting timely, accurate, predictable payment outcomes, effective service recovery, transparent issue status, and clear provider-facing communication.

Directs timely, consistent investigation of complex, high-volume, and recurring provider disputes and escalations; prioritizes correction of systemic causes to prevent repeat provider contacts and payment errors.

Builds joint service routines with Provider Relations, Network, contact center / CCSS, Grievances & Appeals, Compliance, and claims vendors to coordinate provider responses, route issues effectively, and close the loop with internal and external customers.

Uses claims dispute trends, DOH/DFS complaint drivers, provider feedback, repeat contacts, and internal stakeholder insights to identify provider pain points, assign cross-functional resolution owners, and verify lasting service improvements.

Directs oversight of claims service operations, including pended claims, new-day inventory, aging, exception and outlier workflows, escalation management, and coordination with external processing partners.

Ensures timely, accurate claims-related investigations and responses for Department of Financial Services (DFS) and Department of Health (DOH) complaints, in partnership with Compliance and Grievances & Appeals and consistent with established regulatory ownership and workflows.

Monitors complaint and dispute cycle times, compliance with required response standards, documentation quality, and recurring causes; ensures corrective-action plans are completed and verified.

Leads claims operational support for CMS, DOH, DFS, and other applicable audits or examinations, including evidence readiness, accurate reporting, remediation tracking, and closure of audit findings.

Partners with Compliance and operational leaders to translate regulatory and payment-policy changes into business readiness needs, control enhancements, staff education, and appropriate implementation requirements.

Owns the claims-related provider experience improvement agenda, promoting timely, accurate, predictable payment outcomes, effective service recovery, transparent issue status, and clear provider-facing communication.

Directs timely, consistent investigation of complex, high-volume, and recurring provider disputes and escalations; prioritizes correction of systemic causes to prevent repeat provider contacts and payment errors.

Builds joint service routines with Provider Relations, Network, contact center / CCSS, Grievances & Appeals, Compliance, and claims vendors to coordinate provider responses, route issues effectively, and close the loop with internal and external customers.

Uses claims dispute trends, DOH/DFS complaint drivers, provider feedback, repeat contacts, and internal stakeholder insights to identify provider pain points, assign cross-functional resolution owners, and verify lasting service improvements.

Directs development of training modules, SOPs, and UAT protocols to ensure operational readiness and knowledge transfer across teams.

Oversees performance and integration of external audit and recovery vendors and strategic initiatives (e.g., MedEx, MCI), ensuring findings are validated and incorporated into systemic improvements.

Performs all duties inherent in a senior managerial role. Approves staff training, hiring, promotions and terminations and salary actions, prepares and ensures adherence to the department budget. Attracts, develops, and retains highly talented delivery manager