[Hiring] Senior Director of Claims and Eligibility Operations @Southern Scripts

Role Description

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.

• Own the strategic direction and operational performance of Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations.
• 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.
• 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.
• Operate as an enterprise leader, proactively identifying cross-functional risks and contributing to company-wide priorities.

Qualifications

• 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.
• 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.

Requirements

• Deep knowledge of PBM claims adjudication operations within a transparent or pass-through model.
• Expert-level understanding of claims adjudication logic.
• Demonstrated understanding of formulary management within the adjudication engine.
• Comprehensive knowledge of NCPDP adjudication transaction formats.
• Deep working knowledge of NCPDP reject code management and adjudication logic.
• Expert understanding of eligibility operations including EDI standards.
• Strong technical orientation with working proficiency in SQL and familiarity with cloud data platforms.
• Excellent written and verbal communication skills.
• High integrity, sound judgment, and demonstrated discretion in handling PHI/PII.
• Thrives in a growth-stage environment.

Benefits

• Medical, Dental and Vision insurance.
• Disability and Life insurance.
• Employee Assistance Program.
• Remote work options.
• Generous Paid-Time Off.
• Annual Reviews and Development Plans.
• Retirement Plan with company match immediately 100% vested.