[Hiring] Director, Claims Process Optimization @CareSource

Role Description

The Director, Claims Process Optimization leads the design, implementation, and ongoing oversight of automation and artificial intelligence capabilities across CareSource claims operations. This position is accountable for identifying where intelligent automation can remove manual effort, building the business case, guiding delivery alongside configuration, information technology, and vendor partners, and proving the result in sustained production performance rather than in pilot metrics.

• Maintain process oversight across assigned claims adjudication and adjustment workflows.
• Monitor the operating budget for the portfolio and manage vendor performance.
• Lead a team of managers, analysts, and process specialists.
• Own the operating performance of assigned claims processes, including:
  • Inventory levels
  • Aged inventory
  • Throughput
  • Auto-adjudication rate
  • Financial and procedural accuracy
  • Regulatory turnaround time
• Build and maintain the claims automation and artificial intelligence roadmap, prioritizing use cases by measurable benefit, implementation effort, data readiness, and regulatory risk.
• Quantify and defend benefit realization after implementation, comparing production results against the baseline captured before deployment and reporting variances.
• Direct end-to-end analysis of assigned claims workflows, using process mapping, time studies, and production data to locate constraints that drive cost, rework, and delay.
• Build the business case for automation and improvement investments, including projected savings, capacity impact, and payback period, then report actual performance against that case.
• Track cost per claim and capacity utilization to inform staffing, sourcing, and automation sequencing decisions.
• Develop and monitor the operating budget for assigned functions and technology initiatives.
• Direct root cause analysis on recurring defects and drive resolution with upstream owners in configuration, provider data, and enrollment.
• Maintain current documented procedures, process controls, and supporting evidence for internal audit and state, federal, and delegated reviews.
• Run the performance management cadence, including daily production reviews, weekly operating reviews, and monthly business reviews.
• Manage outsourced, offshore, and technology vendors against contracted service levels, quality standards, and delivery commitments.
• Participate in vendor selection, statement of work development, and renewal decisions.
• Perform any other job-related duties as requested.

Qualifications

• Bachelor's degree in business, health administration, data analytics, or a related field required.
• Equivalent years of relevant work experience may be accepted in lieu of required education.
• Seven (7) years of health plan claims or healthcare operations experience is required.
• Five (5) years of leadership experience is required.

Requirements

• Practical understanding of automation and artificial intelligence capabilities applicable to claims work.
• Working knowledge of claims adjudication platforms, provider reimbursement methodologies, and standard code sets including CPT, HCPCS, ICD-10, and revenue codes.
• Strong analytical skills.
• Proven change leadership skills.
• Strong financial acumen.
• Clear written and verbal communication, including the ability to present technical detail and operational risk to executive audiences.

Benefits

• Compensation Range: $113,000.00 - $197,700.00.
• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Licensure and Certification

• None

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time.
• Travel is not typically required.

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.