Director, Claims Process Optimization ( Facets Required)

• Maintain process oversight across assigned claims adjudication and adjustment workflows, monitors the operating budget for the portfolio, manages vendor performance, and leads 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, and 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 the 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, and use both 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 rather than absorbing rework downstream.
• Maintain current documented procedures, process controls, and supporting evidence so the operation stays ready for internal audit and for state, federal, and delegated reviews.
• Run the performance management cadence, including daily production reviews, weekly operating reviews, and monthly business reviews, so risks surface while there is still time to act on them.
• 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, ensuring service levels, data protection terms, and automation expectations reflect operational reality.
• Perform any other job related duties as requested.

• 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

• 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

• None

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

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. 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.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business