Lead Director Adjustments Operations Meritain TPA

CVS Health•Amherst, MA

6d•Hybrid

About The Position

Provides strategic leadership, management oversight, and cross‑functional partnership to ensure exceptional customer experiences and satisfaction. This role is responsible for developing and executing Adjustments, Flex/CDHP, Front End, and Data Operations strategy as well as process automation and outsourcing; leading a multi‑layered organization; monitoring quality, performance, and compliance; resolving escalated issues; and driving continuous process improvement. Applies strong leadership capabilities, a customer‑centric mindset, and advanced problem‑solving skills to drive customer loyalty, retention, and advocacy, while cultivating a positive, service‑oriented, and performance‑driven culture. The position may be remote or hybrid anywhere in the US depending on candidate location and commute to a hub location.

Requirements

Minimum of 10 years leading Claims & Adjustments Operations organizations with deep understanding of healthcare claims operations, adjudication, and preferably in TPA operating models
Healthcare experience within the TPA sector of healthcare delivery highly preferred
Track record of building strong leadership pipelines, succession planning, and employee engagement
Proven experience managing enterprise‑scale operations with complex workflows
Strong execution and delivery skills, including planning, implementation, and operational sustainment
Advanced proficiency in business intelligence and data‑driven decision making
Demonstrated ability to collaborate effectively in matrixed, cross‑functional environments
Strategic problem solving and decision making
Leadership agility and growth mindset
Developing leaders and high‑performing teams

Nice To Haves

Demonstrated success leading large‑scale operational transformation and change initiatives
Working knowledge of healthcare regulatory, compliance, and audit requirements (e.g., HIPAA, CMS, state regulations)
Experience leading or supporting system implementations, optimization, or modernization efforts
Familiarity with automation, AI, workflow tools, and digital claims technologies
Strong financial acumen, including budget ownership, cost management, and workforce optimization
Experience leading remote or hybrid Operations workforces (if applicable)

Responsibilities

Lead a team of 10 people leaders with a total span of control of 171 resources
Provide strategic direction and operational leadership for Adjustments and Recoveries processing delivery, quality, and customer experience
Develop and execute strategies to optimize Adjustments Operations performance, efficiency, and scalability
Implement industry best practices and continuous improvement methodologies (e.g., Lean, Six Sigma, Agile) to streamline processes and improve outcomes
Evaluate, select, and integrate innovative technologies and systems to enhance Adjustments and Recoveries Operations and customer support capabilities
Partner closely with IT, data management, compliance, finance, and other cross‑functional stakeholders to align operational execution with enterprise strategy
Manage workforce planning, capacity models, and resource allocation to ensure services are delivered on time, within budget, and at required quality levels
Establish, monitor, and manage key performance indicators (KPIs), SLAs, and quality metrics
Drive strong performance management, accountability, and results across leadership teams
Foster a customer‑centric culture focused on empathy, effective communication, quality, and problem resolution
Monitor customer feedback, trends, and escalations; implement actions to improve satisfaction, retention, and overall experience
Leverage business intelligence, data analytics, and operational insights to drive informed decision‑making
Stay current on healthcare claims, TPA industry trends, regulatory changes, and emerging technologies to continuously enhance service delivery