Director, Claims Operations

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee Gravie's comprehensive claims operations, including production processing, stop loss, support and appeals, and claims payments.

• Take responsibility for the entire claims processing lifecycle, ensuring accountability for throughput, quality, timeliness, auto-adjudication targets, and first-pass resolution.

• Analyze claims-processing error patterns, identify underlying causes, and implement ongoing quality enhancements.

• Manage stop loss claims production, encompassing adjudication, inventory oversight, quality assurance, and team performance metrics.

• Supervise Claims Managers and the payments team through effective coaching, constructive feedback, and career development initiatives.

• Guarantee accurate and prompt claims payments that fulfill contractual, regulatory, prompt-payment, and network-partner obligations.

• Advocate for claims automation and process enhancement in collaboration with Optimization, Product, Engineering, and Configuration teams.

• Oversee claims inventory, project volume and staffing requirements, perform reviews, and mitigate backlog issues.

• Act as the primary claims operations liaison for Finance, Sales, Account Management, and Clinical teams.

• Manage relationships and performance with payment, recoupment, and claims-processing vendors.

• Uphold compliance, financial controls, transparency, accuracy, and safeguards against fraud, credit balance risks, and other operational threats.

⛳️ Requirements

• Bachelor’s degree or equivalent experience.

• Over 8 years of experience in healthcare claims operations, covering production processing, stop loss, support and appeals, and claims payments.

• More than 3 years of experience in leadership roles managing teams.

• Strong understanding of claims adjudication processes, stop loss mechanics, coordination of benefits, subrogation, recoupment, and principles of payment integrity.

• Proven experience in identifying and fostering automation and process improvements in environments with heavy manual workloads.

• Familiarity with claims platforms and EDI workflows.

• Capability to define decision rights, establish operational norms, create escalation paths, facilitate cross-team communication protocols, and manage inventory practices.

• Proficiency in analyzing operational metrics, recognizing trends, and developing quantitative justifications for process or structural modifications.

• Valid authorization to work in the United States.

🏝️ Benefits

• Coverage for alternative medicine.

• Flexible paid time off (PTO).

• Up to 16 weeks of paid parental leave.

• Paid holidays.

• 401(k) retirement plan.

• Transportation benefits.

• Education reimbursement program.

• Two days of paid paw-ternity leave.

• Equity options.

• Bonus opportunities.