Senior Administrator of Claims in Detroit, Michigan at DETROIT WAYNE Integrated HEALTH Network

Detroit Wayne Integrated Health Network

Job Description

Job Title

Senior Administrator of Claims

Department

Administration

Reporting Structure

Deputy Chief Executive Officer

Pay Grade/Salary

11

Exempt/Non-Exempt

Exempt

Bargaining Unit:

At-Will

Work Location

Varies

Employment Status (FTE)

Full-Time

1.0

Job Summary

Under the general supervision of the Deputy CEO, the Senior Administrator of Claims provides strategic leadership, administrative oversight, and operational direction for the Detroit Wayne Integrated Health Network (DWIHN) claims administration function. This position is responsible for ensuring the accurate, timely, consistent, and compliant adjudication and payment of provider claims in accordance with applicable federal and state laws, Michigan Department of Health and Human Services (MDHHS) requirements, Medicaid and Medicare guidelines, DWIHN policies, provider contracts, and established reimbursement methodologies.

The Senior Administrator of Claims oversees the development, implementation, and continuous improvement of claims policies, procedures, systems, internal controls, quality assurance practices, and performance monitoring processes. The position promotes financial accountability, payment accuracy, appropriate utilization of resources, and equitable treatment of providers while safeguarding public funds and protecting the integrity of DWIHN's claims administration processes.

This position works collaboratively with executive leadership, finance, clinical operations, compliance, information technology, utilization management, provider network management, and other internal and external stakeholders to resolve complex claims issues, strengthen operational effectiveness, mitigate financial and regulatory risk, and support DWIHN's organizational objectives. The Senior Administrator of Claims is accountable for claims performance, staff leadership and development, vendor oversight, regulatory reporting, audit readiness, and the implementation of data-driven strategies that improve service delivery and operational efficiency.

Essential Duties & Responsibilities

Strategic Leadership and Claims Administration

1. Provides strategic direction and administrative oversight of the Claims Unit, ensuring that claims operations align with DWIHN's organizational priorities, financial objectives, contractual obligations, and regulatory requirements.
2. Develops, implements, and evaluates departmental goals, operational plans, performance standards, and long-term strategies to support accurate, timely, and efficient claims processing and payment.
3. Establishes and maintains standardized claims administration policies, procedures, workflows, and operational controls to promote consistency, accountability, transparency, and equitable claims determinations.
4. Directs the daily operations of the Claims Unit, including claims intake, review, adjudication, adjustment, payment processing, reconciliation, reporting, and resolution of outstanding claims issues.
5. Establishes clear expectations for claims management staff and ensures accountability for productivity, accuracy, timeliness, quality, and compliance with established performance standards.
6. Evaluates claims operations to identify systemic challenges, operational deficiencies, emerging risks, and opportunities for improvement, and implements corrective and preventive measures as appropriate.
7. Provides executive leadership with timely updates regarding claims performance, significant operational issues, financial exposure, compliance risks, and recommended corrective actions.

Claims Accuracy, Payment Integrity, and Financial Accountability

1. Oversees claims adjudication and payment processes to ensure that provider claims are processed accurately and in accordance with covered benefits, provider contracts, authorization requirements, coding standards, reimbursement policies, and applicable regulations.
2. Establishes and monitors internal controls designed to prevent, identify, and address duplicate payments, inaccurate reimbursement, improper billing, overpayments, underpayments, inappropriate claims adjustments, and other payment integrity concerns.
3. Ensures appropriate separation of duties and adequate internal controls between claims submission, review, adjudication, approval, payment authorization, reconciliation, and audit functions, as applicable.
4. Establishes review and approval protocols for high-dollar claims, complex claims, manual adjustments, exceptions, and other transactions requiring elevated administrative oversight.
5. Monitors claims expenditures, payment trends, outstanding liabilities, adjustments, recoveries, and other financial indicators to identify potential risks and support sound financial management.
6. Collaborates with Finance and other appropriate departments to reconcile claims payments, investigate discrepancies, resolve payment variances, and ensure the integrity of claims-related financial data.
7. Ensures that claims processing practices support the appropriate use of public funds and comply with applicable Medicaid, Medicare, MDHHS, contractual, and DWIHN requirements.
8. Identifies opportunities to strengthen payment accuracy, reduce administrative waste, improve recovery processes, and mitigate inappropriate or unsupported expenditures.

Regulatory Compliance, Audit Readiness, and Risk Management

1. Ensures claims operations comply with applicable federal and state laws, MDHHS policies and contractual requirements, Medicaid and Medicare regulations, HIPAA privacy and security requirements, and DWIHN policies and procedures.
2. Develops and maintains claims-related policies, procedures, documentation standards, and internal controls necessary to demonstrate compliance with applicable regulatory and contractual obligations.
3. Coordinates claims-related activities associated with internal audits, external audits, financial reviews, regulatory examinations, compliance assessments, and reviews conducted by MDHHS or other authorized entities.
4. Oversees the development and implementation of corrective action plans in response to audit findings, claims processing deficiencies, compliance concerns, payment discrepancies, and identified control weaknesses.
5. Coordinates with Compliance, Legal, Finance, Quality Management, and other relevant departments regarding claims-related investigations, regulatory inquiries, potential improper payments, and other matters requiring cross-functional review.

Performance Management, Quality Assurance, and Reporting

1. Establishes and monitors key performance indicators (KPIs) and quality measures related to claims processing accuracy, payment timeliness, inventory levels, claims aging, error rates, adjustment activity, provider inquiries, appeals, and regulatory compliance.
2. Directs the preparation, review, and timely submission of accurate management reports, operational dashboards, financial analyses, and regulatory reports required by DWIHN leadership, MDHHS, auditors, and other authorized entities.
3. Analyzes claims data to identify trends, root causes, recurring errors, unusual billing patterns, processing inefficiencies, and opportunities to improve financial and operational outcomes.
4. Develops and implements performance improvement initiatives to address identified gaps, strengthen claims quality, improve processing efficiency, and enhance accountability throughout the claims function.
5. Ensures the integrity, completeness, accuracy, and timeliness of claims data maintained within DWIHN's information systems and reporting platforms.

Provider Relations, Dispute Resolution, and Stakeholder Collaboration

1. Serves as a senior administrative point of contact for complex claims matters involving providers, delegated entities, internal departments, and other authorized stakeholders.
2. Oversees the timely and consistent resolution of provider inquiries, disputed claims, payment discrepancies, claims adjustments, appeals, and escalated complaints in accordance with established policies and applicable requirements.
3. Collaborates with Provider Network Management, Finance, Clinical Operations, Utilization Management, Compliance, and other departments to resolve claims issues requiring multidisciplinary review.
4. Ensures that claims decisions are supported by appropriate documentation, applicable policy, contractual requirements, and established review procedures.
5. Promotes consistent and equitable application of claims policies across the provider network while maintaining appropriate internal controls and safeguarding DWIHN's financial and contractual interests.

Systems, Technology, and Process Improvement

1. Oversees the evaluation and continuous improvement of claims administration systems, automated workflows, reporting tools, and related business processes.
2. Collaborates with Information Technology, system vendors, and relevant departments to identify system deficiencies, resolve processing issues, implement approved updates, and improve the reliability of claims operations.
3. Identifies opportunities to automate manual processes, strengthen system edits, improve data validation, enhance reporting capabilities, and reduce administrative burden.
4. Participates in system testing, implementation planning, user acceptance testing, and validation of claims-related system changes to ensure operational readiness and accurate processing outcomes.
5. Ensures appropriate documentation, access controls, data integrity, and confidentiality safeguards are maintained for claims-related systems and information.

Staff Leadership, Supervision, and Organizational Development

1. Provides leadership, supervision, and performance oversight for claims management personnel and assigned staff, establishing clear responsibilities, measurable expectations, and accountability standards.
2. Directs workforce planning, workload distribution, staffing assessments, succession planning, and resource allocation to support departmental objectives and operational continuity.
3. Provides guidance and consultation on complex claims determinations, policy interpretation, escalated issues, and decisions requiring advanced technical or administrative judgment.
4. Evaluates employee performance, establishes development objectives, recognizes accomplishments, and implements performance improvement or corrective action measures when necessary.
5. Promotes a culture of professionalism, collaboration, continuous learning, accountability, and customer service.
6. Ensures staff maintain appropriate knowledge of applicable laws, regulations, policies, coding standards, provider contracts, covered benefits, and claims administration practices.

Confidentiality, Ethics, and Organizational Accountability

1. Safeguards the confidentiality, privacy, and security of member, provider, financial, and claims-related information in accordance with HIPAA and other applicable laws, regulations, and DWIHN policies.
2. Ensures claims administration activities are conducted ethically, consistently, and in accordance with established standards of professional conduct and organizational accountability.
3. Maintains current knowledge of federal and state legislation, regulatory changes, industry standards, reimbursement requirements, and managed care practices affecting claims administration.
4. Ensures compliance with DWIHN policies, administrative directives, records management requirements, and applicable information security standards.
5. Participates in leadership meetings, organizational initiatives, audits, committees, and cross-functional projects as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S):

The Senior Administrator of Claims must possess the following knowledge, skills, and abilities:

Knowledge

• General Knowledge of DWIHN's mission, policies, procedures, provider network, and behavioral health service delivery system.
• Knowledge of MDHHS policies, Medicaid managed care requirements, and applicable federal and state laws and regulations governing claims administration.
• Knowledge of Medicare and Medicaid claims processing, reimbursement methodologies, covered benefits, provider contracts, and payment policies.
• Knowledge of claims adjudication, claims adjustment, payment reconciliation, claims inventory management, and claims dispute resolution.
• Knowledge of CPT, HCPCS, ICD-10, and other applicable coding and billing standards.
• Knowledge of behavioral health services, including mental health, intellectual and developmental disabilities, and substance use disorder services.
• Knowledge of claims payment integrity, internal controls, audit procedures, fraud prevention, overpayment identification, and financial risk mitigation.
• Knowledge of HIPAA privacy and security requirements and confidentiality standards applicable to protected health information.
• Knowledge of claims administration systems, automated processing procedures, data validation, reporting tools, and systems troubleshooting.
• Knowledge of quality assurance, performance measurement, root cause analysis, and continuous improvement methodologies.
• Knowledge of supervisory practices, employee performance management, staff development, and organizational leadership.

Skills and Abilities

• Strategic leadership, executive administration, and organizational management.
• Claims operations management and technical claims oversight.
• Policy development, implementation, and interpretation.
• Regulatory compliance, audit coordination, and corrective action management.
• Data analysis, trend identification, performance monitoring, and report development.
• Critical thinking, sound judgment, problem-solving, and complex decision-making.
• Process improvement, workflow redesign, and operational efficiency.
• Project management, resource allocation, and organizational planning.
• Conflict resolution, negotiation, and dispute management.
• Written and verbal communication, presentation, and report-writing skills.
• Interpersonal, relationship-building, collaboration, and active-listening skills.
• Ability to interpret complex regulatory, contractual, financial, and operational requirements.
• Ability to manage competing priorities, meet deadlines, and maintain accuracy in a high-volume environment.
• Ability to work effectively with individuals from diverse ethnic, linguistic, cultural, economic, and social backgrounds.
• Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, Outlook, and Teams, and the ability to use claims administration, reporting, and data analysis systems.

Required Education & Experience:

REQUIRED EDUCATION

REQUIRED EXPERIENCE

• 5 years of full-time paid professional experience in claims administration, healthcare administration, human services, social services, mental health, behavioral health, managed care, or a related field.
• Five (5) years of full-time paid professional experience in an executive, administrative, management, or supervisory capacity within healthcare, human services, behavioral health, managed care, or a related setting, including responsibility for claims review, claims administration, reimbursement oversight, payment integrity, or related operational functions.
• Demonstrated experience managing complex operational processes, interpreting applicable policies and regulations, monitoring performance, resolving escalated issues, and implementing process improvements.
• Demonstrated experience leading staff, developing operational procedures, establishing performance expectations, and ensuring accountability for organizational objectives.

PREFERRED QUALIFICATIONS

• Experience overseeing claims operations within a Medicaid-funded behavioral health or public managed care organization.
• Experience with MDHHS requirements, PIHP operations, provider reimbursement, and behavioral health claims administration.
• Experience coordinating regulatory audits, implementing corrective action plans, and strengthening internal controls.
• Experience with claims management systems, data analytics, automated payment processes, and performance dashboards.
• Experience managing claims-related vendors, delegated functions, financial reporting, and cross-departmental initiatives.

Required License(s)/Certifications

WORKING CONDITIONS:

EEOC Statement

DWIHN is an Equal Employment Opportunity Employer committed to fair, consistent, and merit-based hiring practices. All qualified applicants are considered for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, marital status, veteran status, sexual orientation, gender identity, or any other status protected under applicable federal, state, local law.

Employment decisions are based solely on job-related qualifications, demonstrated competencies, and organizational needs. DWIHN maintains policies and procedures designed to ensure that recruitment, selection, promotion and all other employment actions are conducted in a manner that is objective, equitable and non-discriminatory.