tango is a leader in the home health management industry and is preparing for significant growth. Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide comprehensive solutions that improve member outcomes while managing the total cost of care.
As we continue to grow, we are seeking a dynamic and experienced Director, Claims Operations to lead and optimize our claims function, ensuring operational excellence, compliance, and exceptional service delivery.
Position Summary
The Director, Claims Operations is responsible for the overall leadership, performance, and strategic direction of the Claims department. This role oversees claims administration, encounter operations, claims system optimization, compliance, operational reporting, and continuous process improvement initiatives.
The Director Claims Operations will partner closely with Finance, Network Operations, Technology, Compliance, and Health Plan partners to ensure accurate claims processing, timely payments, regulatory compliance, and scalable operational performance. This leader will develop high-performing teams, implement operational efficiencies, and leverage technology to support organizational growth and service excellence.
Key Responsibilities
Claims Leadership & Operational Management
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Lead the day-to-day operations and long-term strategy of the Claims department.
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Establish departmental goals, priorities, and performance expectations aligned with organizational objectives.
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Create and maintain scalable processes that support accuracy, efficiency, compliance, and member/provider satisfaction.
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Develop, mentor, and coach managers and team members to foster accountability, engagement, and professional growth.
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Monitor departmental workloads, productivity, staffing needs, and resource allocation.
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Promote a culture of continuous improvement, operational excellence, and customer service.
Claims Administration & Compliance
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Oversee claims adjudication, payment integrity, and claims processing workflows.
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Ensure compliance with contractual obligations, health plan requirements, reimbursement methodologies, and applicable federal and state regulations.
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Develop and maintain policies, procedures, and operational standards supporting compliant claims administration.
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Monitor quality assurance programs and claims audit activities to identify risks and drive corrective actions.
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Investigate and resolve escalated claims issues and operational concerns.
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Partner with Compliance and Legal teams to support regulatory readiness and audit responses.
Encounter Operations & Data Integrity
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Provide leadership and oversight for encounter submission, reconciliation, monitoring, and issue resolution processes.
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Ensure encounter data is submitted accurately and timely according to health plan requirements.
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Collaborate with operational and technical teams to resolve encounter rejections, discrepancies, and process defects.
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Establish controls and reporting mechanisms that support data integrity and regulatory compliance.
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Drive ongoing enhancements to encounter processes that improve efficiency and transparency.
Systems Optimization & Process Improvement
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Partner with Technology and business stakeholders to optimize claims systems, workflows, and operational tools.
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Oversee claims configuration, testing, implementation support, and enhancement initiatives.
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Identify opportunities to automate manual processes and improve operational scalability.
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Monitor system performance and work proactively to resolve operational barriers.
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Support implementation of new technologies that enhance productivity, reporting, accuracy, and service delivery.
Vendor & Health Plan Partnership
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Manage relationships with third-party vendors and external partners supporting claims operations.
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Collaborate with health plans and stakeholders to address operational concerns, service level expectations, and compliance requirements.
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Participate in business reviews and operational performance discussions with clients and partners.
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Ensure vendor performance aligns with contractual and operational expectations.
Performance Management & Reporting
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Establish and monitor key performance indicators (KPIs) related to claims inventory, turnaround times, payment accuracy, encounter acceptance rates, productivity, quality, and compliance.
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Analyze operational trends and identify opportunities to improve performance and reduce risk.
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Develop and present operational reporting and performance insights to executive leadership.
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Lead initiatives that improve department efficiency, reduce errors, and enhance overall service levels.
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Maintain accountability for meeting organizational and departmental performance objectives.
Cross-Functional Collaboration
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Partner with Finance on claims reconciliation, financial reporting, and operational alignment activities.
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Collaborate with Network Operations, Provider Relations, Compliance, Technology, and other departments to improve business outcomes.
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Support organizational growth initiatives, operational projects, and strategic priorities.
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Serve as a trusted advisor and subject matter expert on claims operations and industry best practices.
Qualifications
Education
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Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field required.
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Master's degree preferred.
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Equivalent combination of education and experience may be considered.
Experience
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7+ years of healthcare claims operations experience, preferably within managed care, payer, Medicare, Medicaid, or health plan environments.
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3+ years of leadership experience managing claims teams and operational performance.
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Demonstrated success overseeing claims adjudication, payment integrity, encounter operations, and compliance initiatives.
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Experience leading operational improvement projects and technology-enabled process enhancements.
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Proven ability to effectively manage cross-functional relationships and operational priorities in a fast-paced environment.
Technical Knowledge
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Strong understanding of healthcare claims processing, reimbursement methodologies, provider contracts, and payment integrity practices.
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Knowledge of encounter submission processes, EDI transactions, claims data workflows, and regulatory requirements.
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Experience with claims management systems, reporting tools, and operational analytics.
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Ability to interpret performance data and translate findings into actionable business solutions.
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Proficiency with Microsoft Office Suite and operational reporting platforms.
Leadership Competencies
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Strategic and operational leadership
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Performance management and team development
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Process improvement and operational excellence
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Change management
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Stakeholder and relationship management
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Decision-making and problem-solving
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Data-driven business acumen
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Effective communication and presentation skills
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Collaboration and influence across all levels of the organization
Success Measures
The Director, Claims Operations will be evaluated on:
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Claims payment accuracy
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Claims inventory management and turnaround times
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Encounter acceptance and reconciliation performance
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Compliance and audit outcomes
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Department productivity and quality metrics
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Employee engagement and retention
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Process improvement initiatives and operational efficiencies
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Health plan and stakeholder satisfaction
tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.
