Director of AI-Enabled Rules Modernization

Florida Blue Group; 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

Volunteer time off

Job summary

Florida Blue Group in Jacksonville, FL, seeks a Sr. Director, Business Rule Modernization to lead assessment, improvement, and monitoring of claims adjudication rules across lines of business.

This role directs a team of Senior Consultants to centralize a rules registry, rationalize logic, and pursue low-code and AI-enabled automation, partnering with IT and Claims Ops for accuracy and governance. The position requires 10+ years in claims adjudication and rules management, with strategic

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.
• Demonstrated ability to apply a structured methodology, such as Assess, Improve, and Monitor, to evaluate and modernize complex rule sets.
• Demonstrated experience identifying and implementing low-code and AI-enabled automation to reduce manual configuration and reconciliation.
• Strategic thinking and planning abilities, with proven organizational skills and the ability to be flexible and work with ambiguity.
• Excellent written and verbal communication skills that scale to all levels of the organization.
• High critical thinking skills to evaluate alternatives and present solutions consistent with business objectives and strategy.
• Demonstrated experience with the concepts, theories, and processes of project management.
• Demonstrated ability to manage people, financial resources, and information.
• Strong demonstrated ability to establish, implement, and manage effective work processes and organizational structure.

Responsibilities

• Sets direction for business rule modernization goals that are aligned to the Core Admin Platform transformation, executive priorities, and adjudication accuracy success criteria.
• Leads a continuous assessment of business rules governing adjudication across all lines of business, including centralizing a single rules registry and inventory across the five platforms where rule logic is currently fragmented.
• Working with IT partners, solution the ability to audit current rule configurations for accuracy, redundancy, and conflict, and documents clear business ownership for each rule.
• Partners with Claims Operations, Payment Integrity, and IT to prioritize rule gaps by risk, cost, member and provider impact.
• Directs the design and implementation of modernized rule configurations, leading rules rationalization initiatives that consolidate fragmented logic into a single, governed source.
• Identifies and implements low-code and AI-enabled opportunities to automate rule configuration and maintenance, reducing manual reconciliation and operational burden.
• Develops and attains shared goals with functional business units and IT to create partnerships and joint accountability for rule modernization outcomes.
• Establishes ongoing governance and controllership that sustain rule accuracy and performance once improvements are implemented.
• Measures and reports on the efficiency and accuracy of systems and processes used to manage adjudication rules, flagging drift or emerging risk for correction.
• Ensures monitoring capabilities deliver a high degree of accuracy and auditability consistent with corporate policy, regulatory standards, and accrediting body criteria.
• Understands the industry and its dynamics as they pertain to adjudication and business rule modernization, serving as a liaison between senior business leaders and the enabling technical team so that business vision and priorities are understood and programs are effectively implemented, including alignment with the enterprise AI Coalition strategy.

Job description

Florida Blue Group in Jacksonville, FL, seeks a Sr. Director, Business Rule Modernization to lead assessment, improvement, and monitoring of claims adjudication rules across lines of business.

This role directs a team of Senior Consultants to centralize a rules registry, rationalize logic, and pursue low-code and AI-enabled automation, partnering with IT and Claims Ops for accuracy and governance. The position requires 10+ years in claims adjudication and rules management, with strategic