Senior Director - Benefit Operations

Are you passionate about making a difference in people's lives? Do you enjoy working in a service-oriented industry? If so, this opportunity may be the right fit for you!

Modivcare is looking for an experienced Senior Director - Benefit Operations to join our team. This role is responsible for providing strategic leadership and oversight of core processes critical to the administration and delivery of Non-Emergency Medical Transportation (NEMT) benefits, ensuring these processes align with client contracts, regulatory requirements, and organizational goals. This role is directly accountable for eligibility management, encounter accuracy, contract compliance, client and member benefit plan management, and utilization management, with a critical focus on maintaining the integrity of client benefits and ensuring operational excellence.

As a key member of the NEMT leadership team, the Leader will oversee the teams executing these processes, ensure proper benefit administration, and collaborate across the organization to support seamless operations and continuous improvement. The ideal candidate is a strong leader with deep expertise in healthcare operations, process ownership, and compliance, combined with strong systems thinking, solutioning, and cross-functional collaboration skills to drive continuous improvement and operational efficacy.

This role...

Client Benefit Integrity:

• Serves as the primary custodian of the NEMT benefit structure, ensuring it is configured, managed, and delivered in strict accordance with client contracts and expectations.
• Conducts regular reviews of benefit administration to ensure proper application of eligibility criteria, encounter data accuracy, and utilization policies.
• Partners with Account Management and Compliance to address gaps or discrepancies in benefit delivery, ensuring timely corrective actions.
• Develops and implements controls to prevent benefit mismanagement, including oversight of audit frameworks and governance models.

Process Ownership and Accountability:

• Drives the strategic vision for process design, execution, and optimization, ensuring alignment with long-term organizational goals.
• Develops and maintains process documentation, such as workflows, SOPs, and compliance checklists.
• Utilizes systems thinking to identify interdependencies and optimize end-to-end workflows for efficiency and scalability.
• Conducts requirements gathering and root-cause analysis to address recurring challenges and design effective solutions.

Operational Excellence:

• Oversees the day-to-day execution of processes, ensuring accuracy, timeliness, and consistency across operations.
• Acts as the escalation point for complex issues related to process performance or cross-functional dependencies.
• Engages with internal teams, such as member services, network operations, and shared services, to resolve bottlenecks and streamline workflows.
• Provides strategic direction and leadership to cross-functional teams responsible for eligibility management, encounter accuracy, contract compliance, and utilization management.

Encounter Data Management:

• Ensures data required for encounter documentation is captured accurately and comprehensively to support regulatory and contractual compliance.
• Ensures encounter data elements comply with the benefit structure and meet state and federal regulatory requirements.
• Partners with Revenue Cycle Management (RCM) teams responsible for encounter submissions to ensure operational processes support accurate data capture.
• Lead strategic initiatives to enhance data integrity and address any gaps in documentation.

Performance Monitoring and Reporting:

• Defines and monitors KPIs for process performance, including accuracy rates, turnaround times, and compliance metrics.
• Develops and implements robust process controls to proactively identify and address issues before they impact encounter data or other downstream processes.
• Leverages data analytics to identify trends, gaps, and opportunities for improvement.
• Presents actionable insights and strategic recommendations to senior leadership and clients as required

Compliance and Risk Management:

• Ensures all processes comply with federal, state, and contractual requirements, including HIPAA, Medicaid, and Medicare regulations.
• Proactively identifies risks and implement controls to mitigate them, ensuring process integrity and compliance.
• Partners with Compliance and Legal to prepare for audits and respond to findings.

Utilization Management:

• Develops and executes a strategic vision for monitoring and optimizing benefit utilization to drive cost efficiency and member satisfaction.
• Analyzes trends in member usage to identify inefficiencies, overutilization, or gaps in service delivery.
• Collaborates with network operations and member services to address utilization challenges and improve outcomes.
• Leads cross-functional initiatives to address systemic utilization challenges and align benefit offerings with organizational goals.

Continuous Improvement:

• Drives initiatives to enhance process efficiency, quality, and scalability, leveraging automation and best practices where applicable.
• Leads root cause analysis for recurring issues and implement corrective actions.
• Uses solutioning techniques to address complex challenges and improve business, operations, and product efficacy.
• Stays informed of industry trends, regulatory updates, and innovations to evolve processes accordingly.

Team Development and Engagement:

• Build and mentor a high-performing team capable of delivering operational excellence.
• Foster a culture of accountability, collaboration, and innovation within the Benefit Administration/Operations function.
• Provide training and development opportunities to ensure team members stay aligned with evolving operational and compliance needs.

Functional Leadership:

• Lead and manage teams responsible for eligibility management, encounter accuracy, contract compliance, and utilization management.
• Establish clear objectives, KPIs, and accountability for all processes under the role’s purview.
• Ensure teams are resourced effectively to meet operational demands and achieve performance targets.

We are interested in speaking with individuals with the following...

• Bachelor's Degree in Business Administration, Healthcare Management, Operations, or a related field required, Master's Degree desired.
• Twelve (12) plus years experience in healthcare operations, benefit administration, or process management, specifically a background in healthcare payer operations.
• Eight (8) plus years leadership responsibility.
• Or equivalent combination of education and/or experience.
• Comprehensive understanding of Medicaid and Medicare requirements, including encounter data processes, healthcare compliance standards, and federal/state regulations.
• Expertise in NEMT operations, transportation benefit administration, or similar healthcare benefit management environments preferred.
• In-depth knowledge of process improvement methodologies, such as Lean or Six Sigma, with a track record of driving operational efficiency.
• Familiarity with contract management principles and encounter submission requirements in healthcare settings.
• Proficiency in data-driven decision-making, including leveraging data analytics to monitor performance, identify trends, and inform strategic priorities.
• Advanced communication and stakeholder management skills, enabling effective collaboration with cross-functional teams, executive leadership, and external clients.
• Skilled in risk assessment and mitigation to ensure compliance and operational integrity in high-stakes environments.
• Proven ability to establish and scale new functional teams, driving their alignment with organizational goals and fostering a culture of accountability.
• Capacity to influence organizational strategy and deliver outcomes that align with broader business objectives.
• Ability to lead cross-functional initiatives, resolve operational bottlenecks, and implement innovative solutions to complex challenges.
• Adept at balancing short-term tactical needs with long-term strategic vision, ensuring sustained operational excellence and scalability.

Salary: $191,900 - $259,100

Bonus eligible based on individual and company performance.

Modivcare’s positions are posted and open for applications for a minimum of 5 days. Positions may be posted for a maximum of 45 days dependent on the type of role, the number of roles, and the number of applications received.  We encourage our prospective candidates to submit their application(s) expediently so as not to miss out on our opportunities. We frequently post new opportunities and encourage prospective candidates to check back often for new postings. 

We value our team members and realize the importance of benefits for you and your family.

Modivcare offers a comprehensive benefits package to include the following:

• Medical, Dental, and Vision insurance
• Employer Paid Basic Life Insurance and AD&D
• Voluntary Life Insurance (Employee/Spouse/Child)
• Health Care and Dependent Care Flexible Spending Accounts
• Pre-Tax and Post --Tax Commuter and Parking Benefits
• 401(k) Retirement Savings Plan with Company Match
• Paid Time Off
• Paid Parental Leave
• Short-Term and Long-Term Disability
• Tuition Reimbursement
• Employee Discounts (retail, hotel, food, restaurants, car rental and much more!)

Modivcare is an Equal Opportunity Employer.

• EEO is The Law - click here for more information
• Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
• We consider all applicants for employment without regard to race, color, religion, sex, sexual orientation, national origin, age, handicap or disability, or status as a Vietnam-era or special disabled veteran in accordance with federal law. If you need assistance, please reach out to us at [email protected]