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   Current UPMC employees must apply in HR Direct

Director of Health Plan Claims Operations


Under the general direction of the Vice President of Claims Operations, the Director of Health Plan Claims Operations assumes responsibility for directing all activities related to claims administration for the health plans core lines of business with a focus on Community Health Choices/LTSS. The incumbent is responsible for the delivery of operational services to the core health plan business. Assists in the development and administration of performance standards compliance assurance process documentation and maintenance, vendor relationship management and governance performance guarantee monitoring and reporting, and general business unit support. The director will be responsible for the creation and maintenance of strategic relationships with both internal and external customers. The Director provides leadership and direction to meet or exceed UPMC Health Plan business objectives.

  • Analyze and enhance employee morale, retention, and engagement across operations.
  • Monitor operational performance and make critical decisions regarding processes to ensure that claims operations contributions to the customer experience are exceeding all expectations.
  • Responsible for leveraging cross-functional resources to expand visibility and enhance predictability of expected results.
  • Responsible for identifying causes for variances and recommending corrective action interventions, systemic solutions or necessary short term actions.
  • Identify and execute on new business development opportunities within the industry as well as with other operational groups.
  • Protect the integrity and confidentiality of all data and patient information through physical and/or electronic means.
  • Monitor operational performance and proactively address service issues prior to escalation.
  • Develop and implement clear strategies and tactics to effectively support the needs the health plan's claims operation departments
  • Lead and own strategic client relationships with existing and new clients ensuring we are always exceeding expectations and growing the Claims organization.
  • Interact and collaborate extensively with internal stakeholders and external customers to drive operational excellence and maintain positive relationships supporting business goals and objectives.
  • Analyze and trend claims related data to identify inefficiencies and implement process improvements.
  • Provide direct leadership to a large staff of both exempt and nonexempt employees to maximize claims operations and operational optimization including coaching, developing, and administration of performance appraisals.
  • Manage operating budget in excess of five million dollars ($5,000,000.00). Control expenses while meeting operational, financial, and service requirements in a high volume, fast paced managed care operations environment.
  • Recruit, develop, manage, and motivate high caliber management staff
  • Direct business process improvement.
  • Direct new business development, presentations, and the management of daily workflows
  • Reward employees based upon contribution and performance.
  • Ensure strict compliance with the terms of service level agreements with key clients, and overall governing metrics as established by the health plan.
  • Provide direction to system support teams to analyze and evaluate customer business environments and works in conjunction with IT to develop requirements for system configuration solutions.
  • Direct varying facets of startup for new operational units, including facilities, operations management, and staffing models and requirements
  • Design, develop, implement and support solutions to meet the medical and financial requirements of the Health Plan.
  • Develop and drive strategy for continually improving operational performance
  • Develop innovative approaches to creating a high performing organization understanding and leveraging industry best practice to delivery best in class/world class operational services.
  • Lead work groups that encompass system users and developers to identify problems and propose solutions.
  • Oversees the timely and accurate processing of claims, encounter forms and other required claims information.


  • Bachelor's Degree in Business or Health Care required.
  • Master's Degree preferred.
  • Ten (10) years direct experience in Managed Care and/or Indemnity Insurance required.
  • Ten (10) years of experience in a management position required
  • Experienced in multi-million dollar budget preparation required.
  • Ability to demonstrate process and project management skills preferred.
  • Background in multiple communication techniques, i.e. written and verbal with demonstrated negotiations skill preferred.
  • Knowledge of Federal Medicare and State Medicaid regulations required.
  • Proficiency in Claim/Revenue analysis, Variance analysis, and Trend analysis.
  • Predictive-Modeling and a thorough understanding of Profit & Loss statements a plus.
  • Knowledge of CMS, hospital coding reports and Medicare Bid proposals is preferred.
  • Experience in CMS and DPW audit processes preferred.
  • In-depth PC knowledge of spreadsheet software, database management, and online reporting software is preferred.
  • Excellent written and verbal communication skills are required.
  • A proven track record in making independent decisions required.

    Licensure, Certifications, and Clearances:

    UPMC is an Equal Opportunity Employer/Disability/Veteran

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At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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