Director, State Health Plan Operations

Blue Cross and Blue Shield of North Carolina

3d • Hybrid

About The Position

The Director of Claims leads the organization responsible for the accurate, timely processing and payment of claims. This role oversees the execution of claims strategy by setting a clear business agenda that drives high performance while effectively managing costs. The Director advances the department’s strategic priorities and ensures the delivery of customer‑centric solutions that support enterprise performance goals. The role is responsible for optimizing resources through effective deployment, cross‑training, and talent development to strengthen inventory management and operational flexibility. In addition, the Director evaluates operational performance by establishing performance targets across provider and customer segments and holding teams accountable for achieving business outcomes.

Requirements

• Bachelor's degree or advanced degree (where required)
• 10+ years’ experience in Health Care Delivery and Operations
• In lieu of degree, 12+ years of experience in related field.
• Deep health plan claims and service expertise
• 5+ years of progressive leadership experience

Nice To Haves

• Strong analytical skills with the ability to drive transformational, consumer centric change while managing operations – highly preferred
• Six Sigma/Continuous improvement experience - highly preferred

Responsibilities

• Set team priorities that align with the organization’s core values, strategic objectives, and key deliverables
• Direct end‑to‑end claims processing, adjustments, and financial recovery activities across commercial, government, and inter‑plan lines of business, leveraging data‑driven analytics to inform decisions and execution
• Partner with operational leads and workforce management to supplement strategy with the development of budgets, staffing models, and operational performance standards
• Lead claims process standardization and automation initiatives in partnership with the Continuous Improvement function
• Collaborate with the Business Advisory team to identify and deliver claims process improvements, including Lean Six Sigma initiatives
• Approve business and technical requirements, oversee initiatives, and prioritize decisions to effectively address evolving business needs
• Partner with the Vendor Management Lead to identify and capture value through alternative staffing models and vendor solutions
• Collaborate with providers and people leaders to develop and implement tailored customer strategies that improve performance and outcomes
• Develop, coach, and motivate leaders and team members to reinforce core values and advance the target operating model
• Leverage and advance analytical capabilities to support strategy execution and operational performance management
• Resolve complex escalations and contribute to training development to maintain and improve service delivery
• End to end inventory management to align with all regulatory, Internal, external and other applicable processing guidelines and timeliness expectations; includes evaluating and adjusting all processing guidelines as required to meet customer expectations
• Report operational updates to the Claims AVP and Health Plan Operations VP; serve as a subject matter expert for Claims Operations

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Number of Employees: 1,001-5,000 employees