Director, Claims Operations
Core
Lead end-to-end claims operations including production processing, stop loss, support, appeals, and payments for a health benefits platform serving small and midsize businesses.
Role type
Director, Claims Operations
Builds
Scalable claims processing workflows and automated adjudication systems
Domain
Healthcare / Insurance Claims
Deliverable
production ML models
Required skills
Claims adjudication logic, Stop loss mechanics, Coordination of benefits, Subrogation, Recoupment, Payment integrity, Process automation, Inventory management, Vendor management, Regulatory compliance
Preferred skills
Experience with claims platforms, EDI workflows, Operational metrics analysis
Responsibilities
Own the full claims processing lifecycle from first pass to payment; Manage a team of Claims Managers and payments staff; Drive automation and process improvement initiatives; Maintain claims inventory and forecast staffing needs; Manage vendor relationships and performance; Ensure adherence to regulatory and contractual requirements
Seniority
Director, strategic leadership & team management