Director, AI-Driven Rules Modernization (Claims)

GuideWell; Jacksonville (FL); On-site; USD 152,000 - 247,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Retirement plan

Paid time off

Travel benefits

Job summary

GuideWell seeks a Sr. Director, Business Rule Modernization to drive end-to-end health of adjudication rules across all lines of business.

You will lead a structured Assess, Improve, Monitor program and manage a team building a centralized rules registry while rationalizing logic across platforms. You will partner with Claims Operations, Payment Integrity, IT, and Policy/Contract Management to prioritize gaps by risk and impact, and to deliver governance that ensures accuracy, auditable control,

Qualifications

• 10+ years related work experience including direct experience with claims adjudication, business rules configuration, or rules engine management.
• Proficient subject matter knowledge of business rules governing claims adjudication, including rule configuration, rules engines, and downstream code management.
• Structured methodology (Assess, Improve, Monitor) to evaluate and modernize complex rule sets.
• Experience identifying and implementing low-code and AI-enabled automation within rules operations.
• Strategic thinking with proven organizational skills and ability to work with ambiguity.
• Excellent written and verbal communication skills at all levels of the organization.
• Experience with project management concepts and processes.
• Ability to manage people, finances, and information.

Responsibilities

• Sets direction for business rule modernization goals aligned to Core Admin Platform transformation and adjudication accuracy.
• Leads continuous assessment of rules across lines of business and centralizes a single rules registry across platforms.
• Audits current rule configurations for accuracy, redundancy, and conflict, documenting clear ownership.
• Prioritizes rule gaps by risk, cost, and impact with business units and IT.
• Directs design and implementation of modernized rule configurations and governance.
• Identifies low-code and AI-enabled opportunities to automate rule configuration and maintenance.
• Fosters partnerships with business units and IT for joint accountability on modernization outcomes.
• Establishes governance to sustain rule accuracy and performance after improvements.

Skills

Leadership

Strategy

Project management

Communication

Low-code automation

AI-enabled automation

Claims adjudication

Rules engine

Education

Bachelor's degree

Job description

GuideWell seeks a Sr. Director, Business Rule Modernization to drive end-to-end health of adjudication rules across all lines of business.

You will lead a structured Assess, Improve, Monitor program and manage a team building a centralized rules registry while rationalizing logic across platforms. You will partner with Claims Operations, Payment Integrity, IT, and Policy/Contract Management to prioritize gaps by risk and impact, and to deliver governance that ensures accuracy, auditable control,