Director, Claims OpEx

The Director, Claims Process Improvement is responsible for establishing and leading the enterprise claims process improvement strategy across the organization. This role provides strategic leadership for initiatives that improve claims performance, increase auto-adjudication, reduce administrative costs, strengthen financial accuracy, enhance regulatory compliance, and advance operational scalability. The Director serves as a key partner to executive leadership, Claims Operations, Configuration, IT, Finance, Compliance, and vendor organizations to identify process improvement opportunities, prioritize initiatives, and deliver measurable business outcomes. As the leader of the Claims Process Improvement function, this role develops the long-term vision, governance framework, operational roadmap, and performance strategy for claims improvement activities. The Director is accountable for driving organizational change, leveraging technology and automation, and building a high-performing team capable of supporting continued membership growth and evolving business needs. Experience: Required: - 8+ years of progressively responsible experience in health plan claims operations, claims process improvement, managed care operations, operational excellence, or related healthcare operations functions. - 3+ years of people leadership, formal team leadership, or enterprise program leadership experience, including responsibility for delivery, coaching, performance, or resource allocation. - Demonstrated success leading complex cross-functional initiatives that improved claims performance, reduced manual effort, improved auto-adjudication, reduced rework, or delivered measurable cost savings. - Deep understanding of end-to-end claims processing workflows, claims lifecycle management, claims configuration concepts, payment accuracy, and claims system dependencies. - Experience translating operational and financial data into executive-level recommendations, business cases, roadmaps, and measurable outcomes. - Experience working in a high-volume, regulated Managed Care or Medicare Advantage environment with exposure to CMS guidelines and regulatory standards. Preferred: - Experience building a new function, standing up governance routines, or scaling teams to support organizational growth. - Experience collaborating with IT, Configuration, vendors, Finance, Compliance, and Operations to implement automation or technology-enabled process improvements. - Experience using reporting, analytics, visualization, or query tools such as Excel, SQL, Tableau, Power BI, or comparable platforms. - Hands-on experience with Facets or comparable claims platforms. Education: Required: - Bachelor’s degree in Healthcare Administration, Business Administration, Finance, Operations, Information Systems, or a related field; or an equivalent combination of education and substantial relevant experience. Preferred: - Advanced degree or relevant certification in healthcare management, process improvement, project management, analytics, or operational excellence. Training: Preferred: - Formal training in Lean, Six Sigma, project management, Medicare Advantage, CMS compliance, claims systems, or process improvement methodologies. Specialized Skills: Required: - Strategic and operational leadership with deep knowledge of claims processes, claims improvement levers, and managed care operations. - Executive presence and ability to communicate with precision, influence without direct authority, and navigate competing priorities across functions. - Advanced analytical and business case development skills, including the ability to interpret data, quantify financial impact, identify root causes, and recommend scalable process improvements. - Strong portfolio management, prioritization, governance, stakeholder management, and delivery-risk management skills. - Ability to lead through ambiguity, define operating models, build team capability, and establish performance accountability in an evolving function. - Strong understanding of compliance, regulatory, audit, privacy, and risk considerations relevant to claims operations and process improvement. Preferred: - Proficiency with data analysis or visualization tools such as Excel, SQL, Power BI, Tableau, or similar tools. - Familiarity with automation, workflow design, claims configuration, and system enhancement processes. Other: Required: - Intermediate to advanced proficiency in Microsoft Office products, including Word, PowerPoint, Visio, and Excel. Preferred: - Experience with Facets claims system or comparable claims administration platform. Pay Range: $130,332.00 - $195,498.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.