Director, Claims Operations

Gravie

5d•$134,000 - $179,000

About The Position

The Director, Claims Operations leads Gravie’s end-to-end claims operations, including production processing, stop loss, support and appeals, and claims payments. The role oversees day-to-day operations across all queues and leads managers and individual contributors while driving process improvement, automation, team accountability, vendor performance, and compliance with contractual and regulatory requirements. The Director owns the full claims processing lifecycle and its throughput, quality, and timeliness; establishes auto-adjudication performance targets; and addresses processing errors through root-cause analysis and sustained improvement plans. The position also owns stop loss claims production, inventory management, quality oversight, and team performance, and serves as the operational partner to EDI and Configuration for intake, routing, system rules, enhancements, and issue resolution. The role manages Claims Managers and a small payments team, supporting coaching, performance feedback, and career development. It ensures accurate and timely payments, improves inventory practices and forecasting, leads operational readiness and adoption for automation, and coordinates with internal teams and external vendors. The Director maintains financial controls and ensures claims, payment, and recoupment processes meet applicable requirements and protect against operational risks.

Requirements

Bachelor's degree or commensurate experience.
At least 8 years of experience in healthcare claims operations, with direct exposure to production processing, stop loss, support and appeals, and claims payments.
At least 3 years of experience leading managers and teams, with a track record of building accountability-driven cultures through organizational change.
Strong working knowledge of claims adjudication logic, stop loss mechanics, coordination of benefits, subrogation, recoupment, and payment integrity fundamentals.
Experience identifying and driving automation and process improvement in manual-heavy environments.
Familiarity with claims platforms and EDI workflows.
Ability to establish clear decision rights and operating norms, including escalation paths, cross-team communication protocols, and inventory management practices.
Comfort working with operational metrics, identifying trends, and quantitatively supporting process or structural changes.

Responsibilities

Own the full claims processing lifecycle across first pass, adjustments, stop loss, support, appeals, and payments, with accountability for throughput, quality, and timeliness.
Set and drive auto-adjudication performance targets and improve first-pass resolution rates.
Assess claims processing error trends, identify systemic root causes, and execute plans for sustained quality improvement.
Partner with Claims Quality and Configuration to implement fixes and track recurring error reductions.
Own stop loss claims production, including adjudication of eligible claims, inventory management, quality oversight, and team performance.
Partner with EDI on stop loss intake and routing, and with Configuration on system rules, enhancements, and processing issue resolution.
Manage Claims Managers and a small payments team; provide coaching, performance feedback, and career development.
Foster ownership, psychological safety, and continuous improvement; partner with HR and the VP of Claims on role scope, growth paths, and performance expectations.
Ensure accurate and timely claims payments that meet contractual, regulatory, state prompt payment, and network partner requirements.
Identify high-volume manual workflows for automation, own operational readiness and adoption, and partner with Optimization, Product, Engineering, and Configuration on implementation.
Transition stable operational workarounds into scalable, steady-state processes.
Maintain and improve claims inventory management across queues; work with the VP of Claims and Finance to project volume and staffing needs, lead regular inventory reviews, and escalate blockers to prevent backlogs.
Serve as the primary claims operations contact for Finance, Sales, Account Management, and Clinical teams; communicate system and process changes before they cause downstream impact.
Partner with Optimization on reporting and analytics and with Configuration on change communication protocols.
Manage operational relationships with payment, recoupment, and claims processing vendors, ensuring performance standards and contractual obligations are met.
Ensure claims operations, payment, and recoupment processes comply with regulatory standards and contractual requirements.
Implement and maintain financial controls that support transparency and accuracy and protect against fraud, credit balance risk, and other operational risk.