Director, Claims Process Optimization ( Facets Required)

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

Job Summary

The Director, Claims Process Optimization leads the design, implementation, and ongoing oversight of automation and artificial intelligence capabilities across CareSource claims operations. This position is accountable for identifying where intelligent automation can remove manual effort, building the business case, guiding delivery alongside configuration, information technology, and vendor partners, and proving the result in sustained production performance rather than in pilot metrics.

Essential Functions

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.

Education and Experience

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.

Competencies, Knowledge and Skills

• 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

Licensure and Certification

None

Working Conditions

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

Compensation Range

$113,000.00 - $197,700.00 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

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

Mission and Values

We are difference‑makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer‑centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

CareSource reserves the right to amend this job description at any time.

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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