Director of Claims AI & Process Optimization

CareSource; United States; On-site; USD 113,000 - 198,000; Full time

Job summary

CareSource seeks a Director of Claims Process Optimization to lead automation and AI initiatives across claims operations. You will shape the roadmap, guide delivery with IT and vendors, and prove sustained production gains beyond pilots.

The role requires 7+ years in health plan claims, 5+ years of leadership, and strong financial acumen to defend ROI and drive care operations excellence.

Qualifications

• Bachelor's degree required; equivalent years of relevant work experience may be accepted
• 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 claims adjudication workflows and budget; manage vendor performance; lead managers, analysts, and specialists
• Own operating performance of assigned claims processes: inventory, throughput, auto-adjudication rate, accuracy, and regulatory turnaround time
• Build and maintain the claims automation and AI roadmap; prioritize use cases by measurable benefit and data readiness
• Quantify and defend benefit realization after implementation; compare production results to baseline
• Direct end-to-end analysis of claims workflows using process mapping and time studies to locate cost, rework, and delay
• Build business cases for automation investments including projected savings and payback period
• Track cost per claim and capacity utilization to inform staffing, sourcing, and sequencing decisions
• Develop and monitor operating budgets for assigned functions and technology initiatives
• Direct root cause analysis on recurring defects and drive upstream resolution
• Maintain documented procedures and controls for internal audit and reviews
• Run performance management cadence: daily, weekly, and monthly reviews
• Manage outsourced, offshore, and vendor performance against SLAs and delivery commitments
• Participate in vendor selection and renewal decisions with clear automation expectations
• Perform other job-related duties as requested

Skills

Automation & AI in claims

Claims systems knowledge

Analytical skills

Change leadership

Financial acumen

Communication skills

Education

Bachelor's degree in business/health administration/data analytics/related field

Job description

CareSource seeks a Director of Claims Process Optimization to lead automation and AI initiatives across claims operations. You will shape the roadmap, guide delivery with IT and vendors, and prove sustained production gains beyond pilots.

The role requires 7+ years in health plan claims, 5+ years of leadership, and strong financial acumen to defend ROI and drive care operations excellence.