Senior Director of Claims and Eligibility Operations

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

📋 Description

• Take ownership of the strategic direction and operational performance for Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations.

• Act as the senior decision-making authority for claims and eligibility issues that surpass Director-level resolution capabilities.

• Establish operational standards, escalation frameworks, and performance benchmarks across various functional areas.

• Represent Claims and Eligibility Operations in discussions with senior leadership, cross-functional initiatives, and during client-facing engagements.

• Collaborate with the VP of Operations and Sr. Director, Enterprise Operations to align on organizational strategy and platform priorities.

• Propel automation, AI-assisted workflows, and continual process enhancement.

• Create and sustain operational dashboards and KPI frameworks.

• Provide senior oversight to ensure accuracy, timeliness, compliance, and continuous improvement in claims adjudication.

• Set standards for the accuracy of benefit design and hold the Director of Claims Processing accountable for the quality of configuration.

• Lead the agenda for the adjudication platform in collaboration with the technology team.

• Ensure that claims operations are audit-ready and comply with ERISA, state PBM transparency laws, relevant regulations, and NCPDP standards.

• Oversee the claims QA and testing framework.

• Provide senior oversight of eligibility data integrity, SLA performance, roadmap execution, and escalations.

• Serve as the primary operational liaison to the technology team for platform-related issues, enhancements, deployments, and change control.

• Ensure operational readiness and continuity during platform changes.

• Collaborate with Compliance and Audit, downstream operations, and client stakeholders.

• Represent the function in finalist presentations and strategic discussions with clients.

• Offer strategic direction and senior oversight to the Directors of Claims Processing and Eligibility Operations.

• Manage hiring decisions, performance standards, and the talent development strategy across the domain.

• Maintain HIPAA compliance and report any discovered violations.

⛳️ Requirements

• A Bachelor's degree is required (in Healthcare Administration, Business, Information Systems, or a related field).

• A minimum of 10 years of progressive experience in PBM claims operations, eligibility management, or closely related healthcare operations leadership.

• Proven experience in a transparent or pass-through PBM environment serving ERISA-qualified self-funded plans.

• Familiarity with ERISA fiduciary obligations, self-funded plan administration, and related regulatory requirements relevant to pharmacy benefit management.

• Documented experience in overseeing claims adjudication, quality assurance, and eligibility functions simultaneously, or at a comparable level of operational complexity.

• A successful track record of leading Director-level teams and driving measurable operational improvements across multiple functions.

• Experience in building or managing a claims QA function within a PBM, health plan, or a closely related healthcare environment.

• Experience in managing operational continuity during technology implementations or significant system changes.

• Extensive knowledge of PBM claims adjudication operations in a transparent or pass-through model, including ingredient cost pass-through pricing, dispensing fee structures, accumulator management, benefit design, and claims accuracy standards.

• Expert-level understanding of claims adjudication logic, including claim edit sequences, formulary and clinical edit interactions, plan design rule configuration, and systematic adjudication issue resolution at the engine level.

• Knowledge of formulary management within the adjudication engine, including tier logic, step therapy, quantity limit enforcement, and prior authorization integration.

• Comprehensive understanding of NCPDP adjudication transaction formats, including D.0 and F6.

• Familiarity with NCPDP reject code management, Coordination of Benefits (COB) standards, and the NCPDP Data Dictionary.

• In-depth understanding of eligibility operations, including EDI standards (X12 834, 270/271), member enrollment workflows, and downstream claims impacts.

• Experience in designing or overseeing claims QA programs, including testing protocols, sampling methodologies, and adjudication accuracy validation.

• Proficiency in SQL and familiarity with cloud data platforms such as Snowflake, AWS, or Azure.

• Ability to translate operational requirements into platform specifications and hold technical partners accountable for delivery timelines.

• Capability to lead two or more Director-level reports.

• Excellent written and verbal communication skills.

• High integrity, sound judgment, and discretion in handling PHI/PII and sensitive operational matters.

• Ability to thrive in a growth-stage environment.

• Willingness to work core hours from 8:00 AM to 5:00 PM CT, with availability for extended hours, weekends, and holidays as needed.

• Up to 20% travel required.

• Preferred: familiarity with comparable claims adjudication and eligibility management platforms; experience in product ownership, roadmap management, or business systems analysis; knowledge of Jira, Zendesk, or Azure DevOps; and operational compliance experience with URAC, NCQA, or SOC.

🏝️ Benefits

• Medical, Dental, and Vision insurance.

• Disability and Life insurance.

• Employee Assistance Program.

• Options for remote work.

• Generous Paid-Time Off.

• Annual Reviews and Development Plans.

• Retirement Plan with company match, immediately 100% vested.