Director, Claims Operations
About The Position
Medica is a nonprofit health plan serving over a million members across multiple states, focusing on personalized healthcare experiences and strong provider partnerships. They foster a culture of accountability, data-driven decisions, continuous learning, and collaboration. The Director, Claims Operations is responsible for overseeing all aspects of claims functions, including processing, payment recovery, issue resolution, and provider appeals. This role requires a skilled leader to ensure high-quality, timely, and accurate service delivery across all business lines in a growing environment. The Director will manage operational performance, costs, and quality outcomes, while driving scalability and standardization to support expansion and complexity.
Requirements
- Bachelor's degree or equivalent experience in a related field.
- 10+ years of work experience beyond degree in healthcare, health plans, and/or claims operations.
- 5+ years of people leadership experience.
- Experience partnering cross-functionally (e.g., Payment Integrity, Finance, IT, Compliance) to deliver end-to-end claims outcomes.
- Strong track record of driving operational performance across service, cost, productivity, and quality metrics.
- Strong analytical and problem-solving capabilities with a focus on root cause analysis and continuous improvement.
Nice To Haves
- Experience with claims platform system migration in a build environment.
- Proven expertise in change management with the ability to lead through change.
- Ability to manage people and process in a highly matrixed and complex organization.
Responsibilities
- Oversee end-to-end claims functions, including claims processing, payment recovery, claim analysis and issue resolution, and provider appeals.
- Ensure high-quality, timely, and accurate service delivery for customers, members, and providers across all lines of business.
- Manage operational performance, cost management, and quality outcomes.
- Drive scalability and standardization to support geographic expansion and increasing complexity.
- Design, implement, and enhance controls and reporting across Claims Operations.
- Own executive-level reporting, including ad hoc requests.
- Provide end-to-end oversight of claims processing from intake through adjudication and payment.
- Manage performance across daily, monthly, and quarterly KPIs, ensuring controls and actions drive service, cost, productivity, and quality outcomes.
- Partner cross-functionally with departments such as Payment Integrity, Customer Service, EDI, Configuration, Finance, IT, Compliance/SIU, and Markets to ensure accurate and timely claims outcomes.
- Build and lead a high-performing organization, driving accountability, talent development, and engagement.
- Drive operational excellence through issue resolution, root cause analysis, and continuous improvement across processes, policies, and technology.
- Continuously assess and optimize people, process, and technology to exceed key performance measures.
- Identify and prioritize improvement opportunities with defined success metrics.
- Develop business cases for large-scale initiatives and oversee execution.
- Represent Claims Operations in governance forums and enterprise committees.
- Lead implementation of strategic initiatives across people, process, and technology.
- Execute changes supporting process improvements, new business integration, and measurable performance outcomes.
- Define and execute an optimized workforce strategy, including BPO partnerships, to drive cost efficiency and scalability.
Benefits
- Competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Director
