Director of Health Plan Operations, Claims

Location: New York City, NY

Department: Operations

Reports To: COO

BACKGROUND

Antidote Health believes healthcare is a basic human right. Our mission is to redefine healthcare by providing affordable, high-quality, accessible care and insurance products. We offer telehealth services in several states and ACA-compliant health insurance plans in Ohio and Arizona, with plans to expand. If you are an experienced, mission-driven team member who can flex and adapt to the shifting circumstances of a growth-stage startup and are passionate about care quality, lowering healthcare costs, and improving health and financial outcomes for members, Antidote has a great opportunity.

JOB SUMMARY

The Director of Health Plan Operations, Claims is responsible for the overall administration and processing of medical claims, ensuring efficiency, accuracy, and full compliance with federal, state, and local regulations. This role supervises the outsourced claims processing team, resolves complex claim issues, analyzes claims data for performance improvements, and works collaboratively with other departments and external partners. The ideal candidate will have deep expertise in healthcare billing and managed care environments. Expertise in ACA, Medicare or Medicaid is preferred although not required.

KEY RESPONSIBILITIES

Core Claims Operations

• Accountable to oversee third-party administrators to ensure claims operations are performed in compliance with federal and state regulations, NCQA accreditation standards and internal policies and KPIs.
• Monitor daily operations of the outsourced claims department, including adjudication, rework, and provider disputes workflow management, backlog control, and process adherence to ensure timely claim resolution.
• Serve as the final escalation point for complicated claims grievances and appeals from providers and legal entities. Review denied claims and make decisions based on policy and regulatory compliance.
• Conduct regular quality audits to maintain high standards of accuracy and minimize errors.
• Identify and implement strategies to enhance the claims process, improve payment accuracy, and achieve cost-containment goals. Use claims data to identify trends and opportunities for operational improvement.
• Oversee provider dispute resolution processes and ensure timely responses and documentation.
• Collaborate with internal departments (e.g., utilization management, compliance, provider operations, finance, and member services) to resolve claims-related issues and ensure seamless operations.
• Define the business requirements for the development of dashboards and reports that support optimal claims operations.
• Interpret data trends and provide actionable insights to leadership and stakeholders.
• Draft claims operations policies and procedures.
• Monitor and report on key performance indicators (KPIs) such as claims turnaround time, auto-adjudication rate, denial rate, payment accuracy, claims volume, and inventory backlog to leadership and stakeholders.

System Implementation and Management

• Oversee selection processes and implementation of claims clearinghouse, subrogation, COB, payment integrity, FWA, and payment optimization vendors.
• Serve as a business lead for claims operations. 
• Act as the project manager collaborating with engineering, data analytics, and vendors to define business requirements, test cases, and implementation timelines. 
• Lead UAT (User Acceptance Testing) and validation of claims logic, pricing, and configuration. 
• Oversee training plans for outsourced claims staff. 
• Monitor performance and support issue resolution and optimization. 

QUALIFICATIONS

•  Bachelor’s degree in healthcare administration, finance, business, or related field (master’s preferred). 
• 10+ years of experience in health insurance claims operations, with 5+ years in a leadership role in a medium to large scale managed care or health plan setting. 
• Experience with claims system conversions or implementations. 
• Strong knowledge of ACA, NSA, and state-specific claims regulations. Experience with claims platforms and EDI transactions. 
• Proven ability to lead teams, manage performance, and drive operational excellence. 
• Excellent analytical, communication, and problem-solving skills.
• Proven leadership skills with the ability to manage, motivate, and mentor a high-volume team.

SKILLS AND COMPENTENCIES

Technical & Operational Expertise

• Claims Adjudication Knowledge: Deep understanding of claims processing workflows, coding standards (ICD, CPT, HCPCS), and adjudication logic.
• Regulatory Compliance: Familiarity with ACA, NSA, and state-specific regulations.
• System Conversion Leadership: Experience managing transitions to new platforms, including testing, training, and go-live support.
• Data Analysis & Reporting: Ability to interpret KPIs, identify trends, and present actionable insights.

Leadership & People Management

• Team Development: Coaching, mentoring, and performance management of claims staff.
• Change Management: Leading teams through operational changes, system upgrades, and process redesigns.
• Conflict Resolution: Handling internal and external escalations, including provider grievances and appeals.

Strategic Thinking & Problem Solving

• Process Improvement: Identifying inefficiencies and implementing automation or workflow enhancements.
• Decision-Making: Balancing compliance, cost, and customer experience in operational decisions.
• Risk Management: Anticipating and mitigating regulatory, financial, and reputational risks.
• Cross-Functional Coordination: Working with engineering, data analytics, finance, compliance, provider operations, and member service.
• Stakeholder Engagement: Communicating effectively with internal leadership, external vendors, and regulatory bodies.
• Documentation & Training: Creating SOPs, training materials, and audit-ready documentation.

Member & Provider Focus

• Service Orientation: Ensuring timely, accurate, and fair claims resolution for members and providers.
• Provider Operations: Supporting dispute resolution, payment integrity, and network satisfaction.

WORK ENVIRONMENT

• This is a hybrid position with a requirement to commute to the New York City office. Must have a quiet, distraction-free workspace to perform duties effectively from home.
• Work location must be secure and private to maintain HIPAA compliance.
• This position may require travel.