Director of Claims

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

Learn more at: https://prominence-health.com/

Job Summary:

The Director of Claims is responsible for leading the strategic direction, planning, and execution of all claims operations. This role oversees departmental leadership, ensures compliance with federal, state, and payer regulations.  This role drives innovation through technology and process optimization. The Director collaborates with executive leadership to align claims operations with organizational goals, manages departmental budgets, and leads cross-functional initiatives to improve service delivery, quality, and operational efficiency. The ideal Director candidate has extensive Commercial, ASO, Medicare and Medicaid claims experience, expertise in claims adjudication systems (QNXT preferred), and a proven track record of strategic leadership in healthcare claims management.

Benefit Highlights:

• Loan Forgiveness Program 
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! · More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com 

Qualifications

Qualifications and Requirements:

• Bachelor’s degree in health care administration or business management, or equivalent work experience.
• 5+ years’ experience in claims management with direct Medicare claims experience. 
• 5+ years’ experience managing, budgeting, forecasting and collaboration with executive leadership.
• Strong leadership skills with an ability to influence and persuade internally and externally while driving cross-functional collaboration.
• Deep understanding of medical terminology, coding systems (CPT, ICD-10), and insurance billing practices. 
• Comprehensive knowledge of healthcare regulations, including HIPAA, CMS guidelines, state laws and experience in information preparation for required regulatory audits.
• Ability to promote data driven decision making throughout the organization.
• Knowledge of benefits, pricing and inventory management and reporting. 
• Expertise in software implementation, technology adoption and an understanding of which tools work best to meet the needs of organization.
• Outstanding interpersonal skills
• Excellent written, oral, and active listening communication skills.
• Proficient in MS Office, contact center and training platforms, workforce management and project/team management software.
• Strong project management skills and experience managing large scale projects.
• Familiarity with claims systems and processes, QNXT system experience strongly preferred.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

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