Director, Claims OpEx

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.