Job Details

Job Description

Morgan Consulting Resources, Inc. has been retained to confidentially search for a Director of Claims & System Configuration for a Texas Department licensed Third Party Administrator (TPA) and Management Service Organization (MSO). This is aremote position with limited travel to Corporate or Client locations as necessary.

About the Company:
We are directly contracted with Fortune 100 and other National health plans for Medicare Advantage. Our primary operating model is leading full-risk value based models which allows us to serve the best interest of our members and providers. Our model is designed to advance the best interests of both members and providers by enabling high-quality, coordinated, and financially aligned care. Through our administrative and clinical infrastructure, providers gain more time to support the complex needs of their patients, participate in robust pay-for-quality programs, and work directly with us rather than navigating multiple health plans.

We deliver a comprehensive suite of services in accordance with regulations established by the Centers for Medicare & Medicaid Services (CMS) and standards set by the National Committee for Quality Assurance (NCQA), including: regulatory compliance, claims processing and payment operations, provider credentialing, medical management services, financial services, revenue cycle management, network management and performance improvement, including population health management, HEDIS/quality improvement, and enhanced value based care initiatives.

About the Position:
Reporting to the VP, Operations, the Director of Claims and System Configuration ("Director") will oversee claims processing, health plan benefit configuration, vendor management, and benefit/contract setup to support timely, accurate adjudication in compliance with CMS, state, and delegated contractual requirements. The Director is responsible for optimizing claims workflows, enhancing system configuration accuracy, driving automation, claim monitoring and audit accuracy, co-lead and support Provider Dispute Resolution appeals, and improving financial and operational performance. This leader partners closely with Provider Network Operations, Medical Management, Compliance, Reporting, Operations, Quality/STARs, and Finance to support organizational goals related to cost containment, encounter accuracy, provider experience, and regulatory compliance.

The successful candidate will be a collaborative leader with deep operational expertise in Medicare Advantage and Medicare Fee-for-Service (FFS) and capitation claims. The ideal candidate will also have strong knowledge of value-based care networks and cost-containment strategies under global risk arrangements, with the flexibility to support additional lines of business as we continue to expand in other products.

Essential Functions:

• Claims Operations Leadership
• System Configuration & Benefit/Contract Setup
• Vendor Oversight & Delegated Functions
• Regulatory & Audit Readiness
• Encounter Data (837) Responsibilities
• Interoperability
• Hierarchical Conditional Coding (HCC) and encounter submission accuracy
• EDI Oversight
• Performance Optimization & Reporting
• Staff Development
• Leadership

Required Experience:

• Minimum five (5) years of experience in healthcare claims operations, with at least three (3) years in a leadership role.
• Direct experience with Medicare Advantage delegated claims (as a delegated entity), and CMS compliance, and prompt pay requirements.
• Experience working in a TPA, delegated MSO, or health plan under MA risk arrangements.
• Hands-on experience with enterprise claims adjudication platforms.
• Experience leading system configuration and benefit/contract setup workflows.
• Demonstrated success managing claims vendors and the readiness to oversee delegated relationships as they are implemented.
• High proficiency with claims auditing, regulatory readiness, and operational metrics.

Required Qualifications:

• Bachelor's Degree in Business Administration, Healthcare Administration, or related field required.
• Certified Professional Coder (CPC) or similar coding certification preferred, but not a requirement.
• Experience with implementing new claims systems or major configuration upgrades.
• Strong analytical, problem-solving, and project management skills.
• Excellent written and verbal communication skills with strong attention to detail.

Organization Culture & Values:

• We foster a collaborative, inclusive, and performance-driven culture built on respect, accountability, and innovation. This role is expected to exemplify these values and inspire operational excellence across all departments.
• This position, along with team members within assigned units and across the organization, fosters an engaging and professional environment committed to respect, inclusivity, continuous improvement, and teamwork.
• The position works within policies and procedures, related to the department and organization, and supports efforts needed for organizational growth, proposal developments, fiscal management and monitoring, reporting and analysis, and supports compliance with local, state, and federal regulations as well as regulatory, controlling, and licensing agencies.
• We provide equal access to and opportunity within the organization and employment, without regard to race, color, creed, religion, national origin, gender, age, marital status, disability, public assistance status, veteran status, sexual orientation, gender identity, or gender expression.

Compensation: This position is expected to pay within the range of $160,000 - $190,000 base with 20% bonus potential. Salary is determined by experience and location. Other benefit options include 401K, Medical, Dental, Life Insurance, and PTO.

Erica Eikelboom, Principal & Executive Search Consultant
...@morganconsulting.com