Director, AI-Driven Claims Optimization

CareSource; Ohio; Hybrid; USD 113,000 - 198,000; Full time

Job summary

The Director, Claims Process Optimization at CareSource leads the design, implementation, and ongoing oversight of automation and AI across claims operations. You will identify opportunities, build the business case, and guide delivery with IT and vendor partners to deliver sustained production improvements.

You will manage end-to-end claims workflows, budgets, vendor performance, and a team of managers and analysts.

Qualifications

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

Responsibilities

• Maintain process oversight across assigned claims adjudication and adjustment workflows.
• Own the operating performance of assigned claims processes, including inventory, throughput, and accuracy.
• Build and maintain the automation and AI roadmap, prioritize use cases and data readiness.
• Quantify and defend benefit realization after implementation and report variances.
• Direct end-to-end analysis of claims workflows using process mapping and production data.
• Track cost per claim and capacity utilization to inform staffing and 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.
• Manage outsourced, offshore, and technology vendors against SLAs and delivery commitments.

Skills

Automation/AI in claims

Claims systems knowledge

Analytical skills

Change leadership

Financial acumen

Executive communication

Education

Bachelor's degree in business/health admin/data analytics

Equivalent years of relevant work experience

Tools

Claims adjudication platforms

Code sets CPT/HCPCS/ICD-10

Job description

The Director, Claims Process Optimization at CareSource leads the design, implementation, and ongoing oversight of automation and AI across claims operations. You will identify opportunities, build the business case, and guide delivery with IT and vendor partners to deliver sustained production improvements.

You will manage end-to-end claims workflows, budgets, vendor performance, and a team of managers and analysts.