Sr Director, Business Rule Modernization

GuideWell•Jacksonville, FL

13d

About The Position

The Sr. Director, Business Rule Modernization owns capability enablement streams supporting the end-to-end health of business rules governing claims adjudication across all lines of business. The role leads a structured Assess, Improve, and Monitor methodology to evaluate rule performance, prioritize and execute modernization of high-impact rules, and sustain accuracy and control after improvements are implemented. The Sr. Director leads Senior Consultants responsible for building a centralized business rules registry, rationalizing logic fragmented across platforms, and identifying low-code and AI-enabled opportunities that reduce manual configuration and reconciliation. The role collaborates closely with Claims Operations, Payment Integrity, Policy and Contract Management, and Information Technology to keep rules accurate, auditable, and aligned with GuideWell’s Core Admin Platform transformation and enterprise AI Coalition strategy. The position sets modernization direction, directs rule assessment and implementation, establishes governance and monitoring, and serves as a liaison between senior business leaders and technical teams. It also manages people, financial resources, and information, and provides input to and influence over business plans and strategies.

Requirements

10+ years of related work experience, including direct experience with claims adjudication, business rules configuration, or rules engine management.
Proficient subject matter knowledge of business rules governing claims adjudication, including rule configuration, rules engines, and downstream code management.
Demonstrated ability to apply a structured methodology, such as Assess, Improve, and Monitor, to evaluate and modernize complex rule sets.
Demonstrated experience identifying and implementing low-code and AI-enabled automation to reduce manual configuration and reconciliation.
Strategic thinking and planning abilities, strong organizational skills, and flexibility working with ambiguity.
Excellent written and verbal communication skills across all levels of an organization.
Strong critical-thinking skills to evaluate alternatives and present solutions consistent with business objectives and strategy.
Demonstrated experience with project management concepts, theories, and processes.
Demonstrated ability to manage people, financial resources, and information.
Strong demonstrated ability to establish, implement, and manage effective work processes and organizational structure.
Strong demonstrated ability to provide input to and influence business plans and strategies.
Knowledge of the system development life cycle.
At least 5 years of direct supervisory or management experience.
Bachelor’s degree or additional related equivalent work experience.
Able to travel to multiple locations for work occasionally, such as for meetings, events, and conferences.
Sedentary work involving exertion of up to 10 pounds of force occasionally to move objects.

Nice To Haves

Experience managing large-scale enterprise projects.
Leadership experience in business operations.
Experience with Diamond or similar core administration and claims adjudication platforms.
Experience applying agentic AI or AI-enabled automation within claims or business rules operations.

Responsibilities

Set direction for business rule modernization goals aligned with the Core Admin Platform transformation, executive priorities, and adjudication accuracy success criteria.
Lead continuous assessment of adjudication rules across all lines of business, including centralizing a rules registry and inventory across five platforms.
Work with IT partners to enable audits of rule configurations for accuracy, redundancy, and conflict, and document business ownership for each rule.
Partner with Claims Operations, Payment Integrity, and IT to prioritize rule gaps by risk, cost, and member and provider impact.
Direct the design and implementation of modernized rule configurations and lead initiatives to consolidate fragmented logic into a governed source.
Identify and implement low-code and AI-enabled opportunities to automate rule configuration and maintenance and reduce manual reconciliation and operational burden.
Develop shared goals with functional business units and IT to establish partnerships and joint accountability for modernization outcomes.
Establish ongoing governance and controllership to sustain rule accuracy and performance after improvements are implemented.
Measure and report on the efficiency and accuracy of systems and processes used to manage adjudication rules, and flag drift or emerging risk for correction.
Ensure monitoring capabilities provide accuracy and auditability consistent with corporate policy, regulatory standards, and accrediting body criteria.
Stay informed about industry dynamics related to adjudication and business rule modernization; liaise between senior business leaders and technical teams so business priorities are understood and programs are effectively implemented.
Align work with the enterprise AI Coalition strategy.
Direct a team of Senior Consultants.
Manage people, financial resources, and information, and provide input to and influence business plans and strategies.