Director, Claims Process Optimization – Facets Required

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

📋 Description

• Oversee the design, implementation, and continual management of automation and artificial intelligence capabilities within claims operations.

• Identify potential areas for intelligent automation, create business cases, facilitate delivery in collaboration with configuration, information technology, and vendor partners, and ensure sustained production performance.

• Supervise claims adjudication and adjustment workflows.

• Monitor the operating budget and evaluate vendor performance.

• Lead a team consisting of managers, analysts, and process specialists.

• Take ownership of operating performance metrics, including inventory, throughput, auto-adjudication rate, accuracy, and regulatory turnaround time.

• Develop and uphold the claims automation and artificial intelligence roadmap.

• Measure and report benefit realization against pre-deployment baselines.

• Analyze workflows through process mapping, time studies, and production data.

• Construct business cases for automation and improvement investments, and report actual performance outcomes.

• Monitor cost per claim and capacity utilization to guide staffing, sourcing, and automation sequencing decisions.

• Create and oversee operating budgets for designated functions and technology initiatives.

• Lead root cause analysis and resolution of recurring defects in collaboration with upstream stakeholders.

• Ensure procedures, process controls, and audit trails are maintained for internal, state, federal, and delegated reviews.

• Conduct daily production reviews, weekly operational reviews, and monthly business reviews.

• Manage outsourced, offshore, and technology vendors to meet service levels, quality standards, and delivery commitments.

• Engage in vendor selection, development of statements of work, and renewal decisions.

• Execute other job-related tasks as assigned.

⛳️ Requirements

• A Bachelor's degree in business, health administration, data analytics, or a related field is required.

• Equivalent years of relevant work experience may be considered in place of the required education.

• Minimum of seven (7) years of experience in health plan claims or healthcare operations is required.

• At least five (5) years of leadership experience is necessary.

• Practical knowledge of automation and artificial intelligence capabilities relevant to claims processing.

• Familiarity with claims adjudication platforms, provider reimbursement methodologies, and standard coding sets, including CPT, HCPCS, ICD-10, and revenue codes.

• Strong analytical abilities.

• Demonstrated skills in change leadership.

• Solid financial acumen.

• Excellent written and verbal communication skills, including the capacity to present technical details and operational risks to executive audiences.

• Typical office environment; may require prolonged periods of sitting or standing.

• Travel is generally not required.

🏝️ Benefits

• Potential for bonuses linked to both company and individual performance.

• Comprehensive total rewards package.

• Support for overall employee well-being.

• Flexible remote work arrangement.