Senior Director of Claims and Eligibility Operations - REMOTE

Southern Scripts•Chicago, IL

11d•Remote

About The Position

The Senior Director of Claims and Eligibility Operations is responsible for the strategic leadership and operational oversight of two critical and interdependent functions within Liviniti's Operations organization: Claims Adjudication and Eligibility Operations. This is a senior leadership role that carries accountability for the accuracy, integrity, and performance of both verticals, and serves as the primary operational and technical authority bridging platform capability with day-to-day execution. The Sr. Director leads a multi-functional domain that includes Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations. The Sr. Director maintains ultimate accountability for the performance and strategic direction of the full domain and is expected to engage the technology team as a peer, represent these functions at the senior leadership level, and drive continuous improvement across the claims and eligibility ecosystem.

Requirements

Deep knowledge of PBM claims adjudication operations within a transparent or pass-through model, including ingredient cost pass-through pricing, dispensing fee structures, accumulator management, benefit design, and claims accuracy standards
Expert-level understanding of claims adjudication logic, including claim edit sequences, formulary and clinical edit interaction, plan design rule configuration, and the ability to identify and resolve systematic adjudication issues at the engine level
Demonstrated understanding of formulary management within the adjudication engine, including tier logic, step therapy, quantity limit enforcement, and prior authorization integration at the point of adjudication
Comprehensive knowledge of NCPDP adjudication transaction formats, including D.0 and F6, with experience supporting standard transitions in a production claims environment
Deep working knowledge of NCPDP reject code management and adjudication logic, Coordination of Benefits (COB) standards for primary and secondary payer scenarios, and the NCPDP Data Dictionary including segment and field-level transaction requirements and billing and reversal transaction flows
Expert understanding of eligibility operations including EDI standards (X12 834, 270/271), member enrollment workflows, and the downstream impact of eligibility data on claims adjudication outcomes
Demonstrated experience leading claims adjudication, quality assurance, and eligibility functions at a senior level within a transparent or pass-through PBM, health plan, or closely related healthcare environment serving ERISA-qualified self-funded plans
Experience designing or overseeing claims QA programs, including testing protocols, sampling methodologies, and adjudication accuracy validation
Demonstrated understanding of how transparent PBM pricing models shape adjudication accuracy standards and client reporting obligations
Strong technical orientation with working proficiency in SQL and familiarity with cloud data platforms such as Snowflake, AWS, or Azure
Proven ability to engage the technology team as a peer, translating operational requirements into platform specifications and holding technical partners accountable to delivery timelines
Experience managing operational continuity through technology implementations or significant system changes
Demonstrated ability to lead through two or more Director-level reports, setting strategic direction while holding each accountable for their functional area's performance
Excellent written and verbal communication skills with the ability to engage technical and non-technical stakeholders, including client representatives and executive leadership
High integrity, sound judgment, and demonstrated discretion in handling PHI/PII and sensitive operational matters
Thrives in a growth-stage environment, bringing structure and clarity where processes are still being built and demonstrating the ability to scale with the organization
Bachelor's degree required (Healthcare Administration, Business, Information Systems, or related field)
10 or more years of progressive experience in PBM claims operations, eligibility management, or closely related healthcare operations leadership
Demonstrated experience in a transparent or pass-through PBM environment serving ERISA-qualified self-funded plans
Working knowledge of ERISA fiduciary obligations, self-funded plan administration, and associated regulatory requirements relevant to pharmacy benefit management
Demonstrated experience owning or providing senior leadership over claims adjudication, quality assurance, and eligibility functions simultaneously, or at a comparable level of operational complexity
Proven track record of leading Director-level teams and driving measurable operational improvement across multiple functions
Experience building or overseeing a claims QA function within a PBM, health plan, or closely related healthcare environment
Experience managing operational continuity through technology implementations or significant system changes

Nice To Haves

Familiarity with comparable claims adjudication and eligibility management platforms
Background in product ownership, roadmap management, or business systems analysis
Experience with operational ticketing and workflow management systems such as Jira, Zendesk, or Azure DevOps
URAC, NCQA, or SOC comparable operational compliance experience

Responsibilities

Own the strategic direction and operational performance of Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations, ensuring each area has clear goals, accountable leadership, and the resources needed to execute
Serve as the senior decision-making authority for claims and eligibility matters that exceed Director-level resolution capacity
Define and maintain operational standards, escalation frameworks, and performance benchmarks across all functional areas
Represent Claims and Eligibility Operations in senior leadership discussions, cross-functional initiatives, and client-facing engagements, including conversations where full claims cost and adjudication transparency is expected by the client
Partner with the VP of Operations and Sr. Director, Enterprise Operations on org-wide strategy and platform priorities
Identify and pursue opportunities for automation, AI-assisted workflows, and process improvement across claims and eligibility operations
Own the development and maintenance of operational dashboards and KPI frameworks across all functional areas, ensuring decisions are data-driven and leadership has consistent visibility into claims accuracy, eligibility performance, QA outcomes, and key operational metrics on a regular reporting cadence
Operate as an enterprise leader, not just a functional one -- proactively identifying cross-functional risks and contributing to company-wide priorities beyond the claims and eligibility domain
Provide senior oversight of the claims adjudication function, ensuring accuracy, timeliness, and compliance with client contractual obligations and regulatory requirements
Own accountability for adjudication quality metrics and continuous improvement plans, driving measurable gains in claims accuracy and processing performance
Set the standard for benefit design accuracy and hold the Director of Claims Processing accountable for configuration quality across all client populations
Drive the adjudication platform agenda with the technology team, setting priorities for enhancements and holding technical partners accountable to production stability standards
Ensure claims operations are audit-ready and compliant with ERISA, state PBM transparency laws, and applicable regulatory standards, including pass-through pricing validation and ingredient cost accuracy
Ensure claims adjudication operations maintain compliance with current NCPDP standards and are positioned to support ongoing standard transitions as they are adopted across the industry, including D.0 to F6
Own the claims QA and testing framework, ensuring systematic validation of adjudication accuracy, benefit configuration, and system changes before and after deployment
Provide senior oversight of the eligibility function through the Director of Eligibility Operations, maintaining ultimate accountability for eligibility data integrity, SLA performance, and roadmap execution
Own the integrity of eligibility data as it flows into downstream adjudication, establishing validation standards and accountability frameworks rather than managing configurations directly
Own senior escalation authority for eligibility issues that require cross-functional resolution or executive visibility
Oversee the eligibility product roadmap at a strategic level, ensuring enhancements are prioritized in alignment with operational and client needs
Serve as the senior operational liaison to the technology team on platform issues, enhancement requests, deployment readiness, and change control processes for both claims and eligibility systems
Ensure all functional areas are represented in platform governance discussions and that operational requirements are clearly communicated to the technology team prior to deployment
Own operational readiness across all functional areas for all platform changes, setting standards for deployment governance and holding each area accountable to readiness requirements
Own accountability for ensuring platform changes are deployed with zero disruption to claims or eligibility processing continuity, with robust change management and contingency planning in place
Possess sufficient technical fluency in SQL and cloud data platforms to evaluate analytical work, interpret data findings, and engage the technology team with credibility
Collaborate cross-functionally to ensure claims and eligibility accuracy supports downstream operations and client outcomes, and represent the function in finalist presentations and strategic client conversations as needed
Collaborate with the Compliance and Audit function to ensure operational QA findings are reflected in audit planning and that the two functions remain clearly delineated in scope and accountability
Provide strategic direction and senior oversight to the Director of Claims Processing and the Director of Eligibility Operations, each of whom is responsible for day-to-day operations and personnel management within their respective functional area
Establish clear standards, escalation paths, and operating frameworks that enable all functional areas to perform effectively under their respective Director's leadership
Own hiring decisions, performance standards, and talent development strategy across all functional areas in partnership with each Director
Abides by all HIPAA obligations related to Protected Health Information (PHI), reports any discovered violations to the Compliance Officer and/or Human Resources, and completes all required HIPAA training offered by the company
Flexibility to understand, appreciate, and embrace that the job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice