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Corporate Director, Employee Health Plan Claims

Prime Healthcare Ontario Full-Time
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The Corporate Director Employee Health Plan Claims provides high level oversight of the entire Claims process from initial claim submission to final payment of all claims for all Employee Health Plans. The Corporate Director Employee Health Plan Claims will interact with all aspects of the Health Plan Team including Utilization Review and Customer Service. In addition, there will be liaison with senior Prime Healthcare Management which includes presentation of formal analyses of plan payments as well as team productivity.


Additional info:

  • This position requires a comprehensive understanding of this process, primarily for a self-insured Exclusive Provider Organization, but also for PPO, ACA and Point of Service Plans.

  • The Director will initially oversee a team of five who oversee the current TPA. In the near future, this team will expand and require development of optimal processes and procedures to pay both facility and professional claims. 

  • This position will require the presentation of formal analyses of plan payments as well as team productivity.

  • While the position is based full-time at Prime Corporate Headquarters in Ontario, CA, some travel may be required.




Required qualifications:

  • A minimum of 5 years’ experience as Director of Claims for a Health Plan, a large IPA or a TPA

  • Minimum BA/BS degree

  • Strong knowledge of medical coding (ICD-10, HCPCs/CPT, etc.)

  • Extensive knowledge of all aspects of Medical Claims both Facility and Professional

  • Certified Professional Coding Certification, AIC, ARM or equivalent

  • Excellent negotiation, analytic and organizational skills

  • Strong management, oral and written communication skills

  • Strong computer skills incl. MS Office skills


    Preferred qualifications:

  • MBA in Healthcare or equivalent degree

  • Advanced computer and MS Office skills

  • Familiarity with multiple Business Intelligence software systems and daily usage of at least one

  • Hands on experience with TPA

  • We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf.


    Skills required

    Decision Making
    Team Building
    Performance Improvement
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    Job ID: 2019-24026


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    Prime Healthcare is an award-winning hospital management company operating 44 acute care hospitals in 14 states. It is one of the nation's leading healthcare service providers with nearly 43,000 employees and staff dedicated to providing the highest quality healthcare and contributing to the communities they serve. Founded in 2001, Ontario, Ca.-based Prime Healthcare is committed to preserving access to healthcare and turning hospitals into thriving, community assets. Prime Healthcare continues to save hospitals, save jobs and save lives.

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