Sr Director, Claims Operations & Provider Configuration

We are a high-performing Managed Services Organization (MSO) supporting a Primary Care Independent Practice Association (IPA) operating under Full-Risk Medicare Advantage Value-Based Care contracts . Our organization partners with primary care providers to deliver high-quality, patient-centered care while managing total cost of care, quality outcomes, and regulatory compliance.
As a fully delegated MSO, we oversee claims adjudication, provider configuration, payment integrity, and operational enablement at scale. Our success depends on disciplined operations, strong provider alignment, and flawless execution across claims, configuration, eligibility, and payment workflows.
Position Summary
The Senior Director of Claims Operations & Provider Configuration is a senior operational leader responsible for end-to-end claims execution, provider setup/configuration, and claims system integrity across a fully delegated, full-risk Medicare Advantage environment.
This role is accountable for ensuring that providers are configured correctly, claims adjudicate accurately, capitation and risk arrangements are honored, and downstream financial, clinical, and regulatory impacts are tightly controlled .
Reporting to the VP of MSO Operations , this role serves as the day-to-day executive owner of claims operations and provider configuration , translating strategic direction into scalable execution. The Senior Director will lead multiple teams, own critical KPIs, partner cross-functionally with Finance, IT, Provider Engagement, Compliance, and Health Plans, and ensure operational readiness for growth, audits, and new market or payor expansion.
Core Areas of Accountability

Claims Operations (Professional, Institutional, Ancillary)
Provider Configuration & Fee Schedule Management
Delegated Claims Adjudication Accuracy & Timeliness
Payment Integrity & Financial Controls
Claims Systems, Rules Engines, and Configuration Governance
Regulatory & Delegation Compliance
Operational Scalability & Process Optimization
Key Responsibilities

Claims Operations Leadership (Full-Risk, Fully Delegated Environment)
Own end-to-end claims operations, including intake, adjudication, pricing, payment, adjustments, reprocessing, and reporting.
Ensure high first-pass adjudication rates, accurate pricing, and timely payment in alignment with CMS, state, and payor delegation requirements.
Establish and enforce standard operating procedures (SOPs) for all claims workflows.
Monitor and manage claims inventory, backlog, turnaround time (TAT), and denial trends.
Serve as the escalation point for complex claims, systemic errors, and provider disputes.
Partner with Finance to ensure claims activity aligns with capitation, IBNR, MLR, and risk pool expectations.
Provider Configuration & Claims System Integrity
Own provider configuration across all claims and delegation systems, including:
Provider demographics
Contract terms
Fee schedules
Risk arrangements
Delegation indicators
Effective dates and terminations
Ensure configuration accuracy prior to provider go-live, acquisitions, migrations, or payor transitions.
Establish a formal configuration governance framework, including validation, QA, and change control.
Prevent configuration-driven leakage, mispricing, or downstream financial exposure.
Partner closely with Credentialing, Contracting, Eligibility, and EDI teams to ensure data consistency across platforms.
Financial Stewardship & Payment Integrity
Ensure claims payment aligns with contractual terms, risk arrangements, and value-based incentives.
Identify and mitigate overpayment, underpayment, and claims leakage risks.
Support recovery initiatives, payment corrections, and reconciliation efforts.
Collaborate with FP&A and Actuarial teams on claims trend analysis, cost forecasting, and variance explanations.
Support internal and external audits related to claims accuracy and provider payment.
Performance Management & KPIs
Define, track, and continuously improve core claims and configuration KPIs, including but not limited to:
First-pass adjudication rate
Claims turnaround time (clean vs. non-clean)
Claims accuracy rate
Configuration error rate
Rework percentage
Provider dispute cycle time
Develop dashboards and operational reporting for VP of MSO Ops, CFO, and executive leadership.
Use data to proactively identify trends, risks, and improvement opportunities.
Compliance, Delegation & Regulatory Oversight
Ensure ongoing compliance with:
CMS Medicare Advantage requirements
State regulatory requirements
Payor delegation agreements
Support health plan audits, CMS audits, and internal compliance reviews.
Maintain audit-ready documentation, policies, and workflows.
Partner with Compliance to remediate findings and implement corrective action plans (CAPs).
Team Leadership & Development
Lead and develop managers and senior staff across claims operations and provider configuration.
Build a high-accountability, metrics-driven culture.
Ensure appropriate staffing models aligned with volume, complexity, and growth.
Coach leaders on problem-solving, escalation management, and continuous improvement.
Drive succession planning and talent development within the department.
Scalability, Growth & Transformation
Prepare claims and configuration operations for:
New payor launches
New market or state expansion
IPA growth and acquisitions
System migrations or upgrades
Lead automation and optimization initiatives to reduce manual effort and error rates.
Serve as an operational lead during integrations, transitions, or platform changes. Qualifications & Experience
Required Qualifications

Bachelor’s degree in Healthcare Administration, Business, Finance, or related field
10+ years of healthcare operations experience, with significant depth in claims operations
5+ years in a senior leadership role managing managers and complex teams
Demonstrated experience in fully delegated, full-risk Medicare Advantage environments
Deep understanding of:
Claims adjudication logic
Provider configuration and fee schedules
Delegation models
Medicare Advantage regulations
Proven ability to operate at scale in a high-volume, high-accountability environment Preferred Qualifications

Master’s degree (MHA, MBA, or similar)
Experience supporting:
Multi-state IPA/MSO operations
Rapid growth or M&A integrations
Strong familiarity with claims platforms, configuration engines, and analytics tools
Lean, Six Sigma, or formal process improvement training Core Competencies

Operational rigor and attention to detail
Strong executive judgment and escalation management
Financial and analytical acumen
Ability to translate strategy into execution
Clear, confident communicator with technical and non-technical audiences
Calm, decisive leadership under pressure
Amm Benefits
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
Career Development: Tuition reimbursement to support your education and growth.