Lead Director Claims Operations Meritain TPA

CVS Health • Amherst, MA

1d • Hybrid

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Brief Overview Provides strategic leadership, management oversight, and cross‑functional partnership to ensure exceptional customer experiences and satisfaction. This role is responsible for developing and executing Claims Operations strategy; leading a large, multi‑layered Claims 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 large‑scale Claims 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 claims 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 Claims Operations workforces (if applicable)

Responsibilities

• Lead a team of up to 20 people leaders with a total span of control exceeding 400 Claims Operations resources
• Provide strategic direction and operational leadership for Claims processing delivery, quality, and customer experience
• Develop and execute strategies to optimize Claims 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 Claims 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

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Director