Executive Director, Medicaid & Duals Claims Operations - Aetna

CVS Health•Hartford, CT

1d•$131,500 - $303,195•Remote

About The Position

Aetna is seeking to hire an Executive Director of Claims Service Operations supporting Medicaid and Duals businesses. This role is accountable for delivering operational excellence across a large-scale, complex environment, with responsibility for claims performance, regulatory execution, automation advancement, vendor governance, workforce strategy, and shared services alignment. The successful leader will partner across health plan, operations, technology, clinical, compliance, and enterprise functions to translate strategic priorities into disciplined operational execution. This individual will drive improvements in claims accuracy, productivity, service performance, and payment integrity while reducing rework, strengthening controls, and enhancing the provider and member experience.

Requirements

12+ years of healthcare operations, managed care, claims, or health plan experience.
2+ years leading direct / indirect employees and developing teams (100+)
Strong knowledge of Medicaid, and/or Duals will be highly valued
Proven ability to influence and collaborate across a highly matrixed organization.
Innovative mind-set. Willing to challenge the status quo.
Proven track record leading large-scale operations across multi-site, remote, and vendor-supported environments.
Strong knowledge of claims operations, regulatory requirements, and operational performance management.
Demonstrated success driving process improvement, automation, and operational transformation initiatives.
Experience partnering effectively across operations, technology, compliance, finance, clinical, provider, and health plan organizations.
Strong executive communication, change leadership, and problem-solving skills.
Proven ability to influence and collaborate across a highly matrixed organization.
Innovative mindset with a focus on driving operational efficiency and continuous improvement.
Strong people leader with a track record of developing talent, holding teams accountable, and navigating difficult conversations.
Ability to thrive in a fast-paced environment and lead effectively through ambiguity.

Nice To Haves

Experience leading shared services operations within a complex matrixed organization.
Experience with auto-adjudication, AI-enabled operations, or digital transformation initiatives.
Background in workforce planning, budgeting, and capacity optimization.
Experience with QNXT or comparable claims platforms preferred.

Responsibilities

Lead a large, multi-market claims operations organization supporting Medicaid and Duals business performance.
Drive operational excellence across claims inventory, timeliness, quality, payment accuracy, productivity, and service level commitments.
Partner with health plan leaders and enterprise stakeholders to align priorities, resolve operational challenges, and execute strategic initiatives.
Establish governance routines that connect operational performance, risk management, issue resolution, and accountability for results.
Advance automation and auto-adjudication strategies to improve cycle times, reduce manual intervention, and increase processing accuracy.
Partner closely with technology teams to prioritize operational enhancements, improve system performance, and support business-driven transformation initiatives.
Support AI-enabled operational capabilities by identifying high-value use cases, defining business requirements, and improving quality and productivity outcomes.
Develop workforce and capacity strategies, including staffing models, resource planning, budgeting, and vendor optimization.
Lead vendor governance through performance scorecards, quality oversight, forecasting, compliance controls, and operational accountability.
Drive continuous improvement initiatives that reduce cost, minimize rework, improve scalability, and strengthen end-to-end claims performance.
Build and develop high-performing teams while fostering a culture of accountability, collaboration, innovation, and execution.