Director, Claims Operations

The role

The Director, Claims Operations will lead end-to-end claims operations including production processing, stop loss, support, appeals, and claims payments. This role manages a team of managers and individual contributors to drive process improvement, automation, and vendor performance.

What you will do

• Own the full claims processing lifecycle including first pass, adjustments, stop loss, support, appeals, and payments
• Assess trends in claims processing errors and execute plans for quality improvement
• Manage stop loss claims production, adjudication, and inventory
• Directly manage a team of Claims Managers and a small payments team
• Ensure accurate and timely claims payment processes meeting contractual and regulatory obligations
• Champion automation and identify manual workflows for improvement
• Maintain and improve claims inventory management
• Serve as the primary claims operations contact for Finance, Sales, Account Management, and Clinical teams
• Manage operational relationships with payment, recoupment, and claims processing vendors
• Ensure claims operations and payment processes meet regulatory standards and contractual requirements

Required qualifications

• Bachelor's degree or commensurate experience
• 8+ years of experience in healthcare claims operations, with direct exposure to production processing, stop loss, support and appeals, and claims payments
• 3+ years of experience leading managers and teams
• Strong working knowledge of claims adjudication logic, stop loss mechanics, coordination of benefits, subrogation, recoupment, and payment integrity fundamentals
• Experience identifying and driving automation and process improvement in manual-heavy environments
• Familiarity with claims platforms and EDI workflows
• Ability to establish clear decision rights and operating norms

Benefits

• Standard health and wellness benefits
• Alternative medicine coverage
• Flexible PTO
• Up to 16 weeks paid parental leave
• Paid holidays
• 401k program
• Transportation perks
• Education reimbursement
• 2 days of paid paw-ternity leave

About the company

Gravie creates health benefits for small and midsize businesses and their employees. The company is led by industry veterans and is well capitalized.