Sr Director, Business Rule Modernization
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 an 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 directs Senior Consultants who build a centralized business rules registry, rationalize logic fragmented across platforms, and identify low-code and AI-enabled opportunities to reduce manual configuration and reconciliation. The position is central to modernizing adjudication rules for an AI-enabled future and collaborates closely with Claims Operations, Payment Integrity, Policy and Contract Management, and Information Technology. It helps ensure rules remain accurate, auditable, and able to scale with GuideWell’s Core Admin Platform transformation.
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 ability to be flexible and work with ambiguity.
- Excellent written and verbal communication skills across all organizational levels.
- 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.
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 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 creation of a centralized registry and inventory spanning 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 based on risk, cost, and member and provider impact.
- Direct the design and implementation of modernized rule configurations, consolidating 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 business units and IT to establish partnerships and joint accountability for modernization outcomes.
- Establish ongoing governance and controllership to sustain rule accuracy and performance.
- Measure and report on the efficiency and accuracy of systems and processes used to manage adjudication rules, identifying drift or emerging risks for correction.
- Ensure monitoring capabilities provide accuracy and auditability consistent with corporate policy, regulatory standards, and accrediting body criteria.
- Serve as a liaison between senior business leaders and technical teams, communicating industry dynamics and business priorities so programs are implemented effectively, including alignment with the enterprise AI Coalition strategy.
- Direct a team of Senior Consultants.
Benefits
- Medical, dental, vision, life, and global travel health insurance.
- Short- and long-term disability programs.
- Leave programs to support personal circumstances.
- Retirement Savings Plan with employer match.
- Paid time off, volunteer time off, 10 holidays, and 2 well-being days.
- Additional voluntary benefits.
- Comprehensive wellness program.
- Competitive pay and opportunities for incentive or commission compensation.
- Annual reviews with pay-for-performance considerations for base pay increases.
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What This Job Offers
Job Type
Full-time
Career Level
Director
