Top 9 Siu fraud Jobs in Doral Fl

Director of TPA Operations
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siu fraud jobs near doral fl

Director of TPA Operations

Provider Network Solutions LLC -
Miami, FL

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Job Details

Full-time
$100,000 - $120,000 a year
13 days ago

Qualifications

Cost management
Pricing
HIPAA compliance
Process audits
Finance
Health insurance policy knowledge
HIPAA
Cost control
Incident Escalation
IT experience within insurance industry
State healthcare regulations
Finance
Medical claims processing software
Insurance regulation
Industry knowledge of financial regulations
Leading team collaboration initiatives
Regulatory readiness in healthcare
Healthcare financial management
Operational excellence initiatives
Process improvement planning
Medical billing regulations compliance
Escalation handling
Cross-functional team management
Health insurance management
Cross-functional communication

Full Job Description

Description:

Position Summary

The Director of Claims Operations is responsible for leading end-to-end claims operations, benefit configuration, compliance, and performance management across health plan partnerships. This role provides strategic and operational leadership to ensure accurate, compliant, and efficient claims processing while driving automation, payment integrity, and continuous improvement at scale.

Duties and Responsibilities

Lead enterprise claims operations strategy and execution, overseeing the full claims lifecycle to ensure accuracy, timeliness, cost containment, and compliance with contractual and regulatory requirements.
Direct benefit configuration and claims system governance, translating health plan contracts, reimbursement methodologies, and benefit designs into scalable, accurate system logic while overseeing change control, testing, and release validation.
Provide senior-level operational leadership and escalation management, resolving complex claims issues, adjudication exceptions, and cross-functional challenges while ensuring continuity, risk mitigation, and service level performance.
Ensure regulatory compliance, audit readiness, and risk oversight, maintaining operational controls, supporting internal and external audits, and proactively adapting processes to regulatory and delegated oversight requirements.
Oversee payment integrity, fraud prevention, and financial stewardship, partnering across compliance and investigative teams to reduce leakage, manage recoveries, and improve overall financial performance.
Drive data-informed performance management and reporting, leveraging analytics to monitor SLAs, KPIs, utilization trends, and operational effectiveness while informing strategic planning and executive decision-making.
Serve as the primary executive liaison for health plans and providers, leading operational reviews, governance forums, and escalations while maintaining strong, trusted external partnerships.
Champion technology modernization, automation, and AI-enabled solutions, leading initiatives that improve throughput, accuracy, scalability, and long-term operational resilience.
Lead organizational growth, change management, and team development, building scalable operating models, developing leadership talent, managing succession planning, and ensuring teams are prepared for system changes, regulatory shifts, and new partnerships.

Requirements:

Knowledge

7–10+ years of progressive experience in TPA operations, managed care, health insurance, or specialty healthcare administration
Deep knowledge of the end-to-end claims lifecycle, including intake, adjudication, pricing, edits, denials, and payment
Hands-on understanding of benefit configuration and reimbursement methodologies within a payer or TPA environment
Working knowledge of third-party administrator operating models, including acting as the intermediary between health plans and provider groups
Strong understanding of payer contracts, fee schedules, benefit designs, and delegated vs. non-delegated arrangements
Proficiency with claims administration platforms (e.g., QNXT, QuickCap, or equivalent)
Strong regulatory knowledge, including CMS, HIPAA, ERISA, state insurance regulations, and payer compliance requirements
Knowledge of audit standards and oversight, including internal audits, external audits, and delegated oversight reviews
Familiarity with fraud, waste, and abuse (FWA) concepts, payment integrity controls, and SIU collaboration
Bachelor’s degree in healthcare administration, Business, Finance, or related field (or equivalent experience)

Skills

Executive-level leadership with the ability to drive accountability, performance, and cross-functional collaboration
Strong operational decision-making and escalation management in complex, multi-stakeholder environments
Advanced analytical capability to interpret claims, financial, and operational data and drive strategic action
Proven ability to lead process improvement, operational efficiency, and cost containment initiatives
Clear, confident communication with health plans, providers, auditors, executives, and internal teams
Effective change management and ability to lead teams through growth, system enhancements, and regulatory change
Strong partnership skills with technology, compliance, finance, and operations leaders to deliver enterprise outcomes

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siu fraud jobs in doral fl

Director of TPA Operations

SIU Investigator

SIU Investigator

SIU INVESTIGATOR - Miami, FL

Licensed Private Investigator - Surveillance

Florida, Miami Surveillance Investigator PT

Florida, Miami SIU Investigator

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