Director of Claims

Job Locations US-RI-Smithfield
Req No.
Regular Full-Time


This position will provide leadership to the Claims Inventory, Claims Production, Provider Call Center and Claims Payment Integrity teams. He/she will be responsible for the tactical and strategic operations/direction of these teams. Being successful in this position includes exceeding provider expectations by ensuring world-class service and support to all of the company’s providers and members as well as providing claims processing services that surpass state/federal regulations and contractual obligations.


The Claims Inventory team handles all incoming claims and follows through until all claims are in the system. The Claims Product Team insures everything received is initially processed (onshore and offshore). The Claims Payment Integrity Team ensures all COB/TPL processes are followed. Creates all internal and external process documents as well as manages all claims recovery vendors. The Provider Call Center team handles all provider calls related to claims and ensures satisfactory closure of issues along with appropriate claims adjudication.


He/she will assess the impact of new business on the overall claims processes and implement initiatives in those areas that will provide the necessary operational support to contribute to successful expansion into new markets. He/she will identify dependencies on other areas and work with peers to ensure that operations are aligned with corporate goals.


  • Serves as the subject matter expert and lead on functional deliverables ensuring optimal efficiency of Claims Processing and Quality
  • Provides leadership related to Claims Inventory, Call Center, Production and Payment Integrity
  • Provides leadership related to consistent business process improvement
  • Own overall oversight and coordination with third party vendors and accountable for ensuring Service Level Agreements (SLA) established with vendors are met consistently
  • Coordinate and ensure timely and accurate implementation of special projects, many of which are cross-departmental. Develop and implement detailed project plans including delineated project tasks, resource requirements, interdependencies and timeliness
  • Keep current on organizational and industry issues, skills and practices and translate this knowledge into effective improvements within the Claims Processing and Quality
  • Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
  • Oversee the operations of the Claims Processing team, ensuring that claims are processed accurately and in accordance with state/federal regulations and contractual obligations
  • Monitor proposed/approved changes to state and federal law, assess the impact on claims processing; and institute/coordinate changes as required to remain compliant with regulations governing his/her assigned staff functions (e.g.: HIPAA, Prompt Claims Processing Act)
  • Assess the impact of new business on the claims processing functions and implement initiatives that will provide the necessary operational support to contribute to successful expansion into new areas
  • Work with the Senior Management Team in the development and implementation of the strategic and annual plans
  • Develop and manage operating and capital budget for the department
  • Departmental Planning:
    • Develop vision and strategy for assigned functions
    • Develop and implement work plans that are consistent and supportive of the company’s strategic and annual plans
    • Support and mentor managers in execution of their respective work plans
    • Ensure that department/appropriate policies and procedures are maintained
  • Represent the company in appropriate committees, work groups and meetings
  • Other duties as assigned
  • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents



  • Bachelor’s degree in Business or Health-related discipline
  • Ten (10)+ years of experience guiding and directing claims operations
  • Five (5)+ years of health care experience, preferably in managed Medicaid / Medicare
  • Five (5)+ years of experience managing third party vendors (onshore and offshore)
  • Minimum of Five (5) years in leading claims processing functions in a managed care organization
  • Experience in Medicaid, Medicare and Commercial lines of business operations
  • Demonstrated effectiveness in strategic planning
  • Demonstrated ability to work with C-level executives to define and implement strategies that led to significant competitive advantage in the marketplace
  • Demonstrated leadership effectiveness, analytical capability, business process improvement and ability to design and implement constructive change
  • Demonstrated communication, organization, project management and interpersonal skills
  • Demonstrated knowledge of best practices that drive an environment of continuous improvement
  • Broad knowledge of the managed care industry and demonstrated ability to apply that knowledge to improve performance and impact the stability of the enterprise


  • Master’s degree in Business or Health-related discipline
  • Experience with Special Investigation Units or other activities related to the identification/monitoring of fraud, abuse and waste activities as it relates to claims payment
  • Ability to evaluate applicable technologies and effectively support implementation required technology changes

Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at


Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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