Director, Operations – Claims Execution

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

📋 Description

• Provides strategic and operational direction for the Claims Execution organization, ensuring timely, precise, compliant, and cost-effective completion of all operational tasks within Claims Operations.

• Oversees the daily management of operational work queues, including operational intake, complex claims processing, provider dispute resolution (PDR), encounter operations, adjustments and reprocessing, member reimbursements, correspondence management, check run operations, and other designated operational functions.

• Acts as the department's expert in operational inventory management, workload prioritization, capacity planning, queue governance, aging management, and operational performance.

• Develops and upholds operational standards, workflows, service level expectations, and performance metrics to guarantee consistent execution and efficient inventory management across all Claims Execution functions.

• Provides oversight and performance management for the Business Process Outsourcing (BPO) claims processing vendor, monitoring production performance, quality, inventory management, turnaround times, service level agreement compliance, issue resolution, and continuous operational improvement.

• Tracks operational inventories, identifies emerging risks, capacity limitations, backlog trends, and aging work items, and implements corrective measures to sustain operational performance and regulatory compliance.

• Leads, develops, mentors, and assesses management and staff within Claims Execution, promoting a culture of accountability, operational excellence, continuous improvement, and customer service.

• Sets operational priorities and allocates resources to ensure balanced workloads, achievement of service levels, and effective execution of organizational priorities.

• Collaborates with Claims Business Operations to pinpoint operational defects, workflow inefficiencies, automation opportunities, and business improvement initiatives aimed at enhancing operational performance and minimizing manual tasks.

• Engages with Configuration, Information Technology, Finance, Compliance, Provider Network Operations, Payment Integrity, Customer Service, and other internal and external business partners to address operational challenges and support enterprise initiatives.

• Ensures adherence to all relevant federal and state regulatory requirements, contractual obligations, organizational policies, and operational standards governing Claims Operations.

• Manages operational readiness and implementation of new regulatory requirements, business initiatives, products, systems, and organizational changes affecting Claims Execution.

• Monitors departmental performance through key performance indicators, operational dashboards, inventory metrics, quality measures, and service level reporting, taking corrective actions as necessary to meet operational goals.

• Develops and maintains departmental procedures, operational controls, and standard operating practices that encourage consistency, quality, efficiency, and regulatory compliance.

• Represents Claims Execution in cross-functional committees, operational governance meetings, vendor discussions, regulatory dialogues, and executive leadership forums.

• Identifies opportunities to enhance provider and member experience by minimizing operational defects, improving turnaround times, strengthening operational controls, and elevating service delivery.

• Performs additional duties as assigned.

⛳️ Requirements

• Bachelor's degree in Business Administration, Healthcare Administration, Public Administration, or a related field; or an equivalent combination of education and progressively responsible experience in managed healthcare operations.

• A minimum of eight (8) years in progressively responsible roles within managed care claims operations, including leadership responsibilities for claims processing, operational management, provider dispute resolution, encounter operations, payment operations, or related healthcare administrative functions.

• At least five (5) years of leadership experience managing operational teams, supervisors, managers, or large-scale operational functions within a managed care, health plan, third-party administrator (TPA), or healthcare payer environment.

• Proven experience leading complex operational organizations with responsibilities in inventory management, workload planning, operational performance, quality, regulatory compliance, and service delivery.

• Experience managing or overseeing outsourced operational services, vendor relationships, or Business Process Outsourcing (BPO) operations is highly preferred.

• Demonstrated experience in leading operational change initiatives, workflow redesign, process improvement, automation initiatives, or organizational transformation efforts.

• Equivalent In lieu of degree: Experience in any combination of academic education, professional training, or work experience that demonstrates the ability to perform the duties of the position will be accepted.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements

• Professional development