Executive Director, Claims Operations & Strategy

MetroPlusHealth; New York (NY); On-site; USD 150,000 - 210,000; Full time

Job summary

MetroPlusHealth in New York is seeking a senior leader to oversee the Claims organization, acting as second-in-command to the VP of Claims. You will direct medical, behavioral health, and BPaaS operations, ensuring timely, compliant adjudication across all product lines.

This role requires extensive knowledge of managed care, CMS and NY regulations, and a track record of leading large teams through transformation.

Qualifications

• Eight or more years of progressive health plan claims operations experience.
• Seven or more years of leadership experience managing managers and senior leaders.
• Experience with Medicare, Medicaid, Commercial, Marketplace, and Special Needs products.
• Experience leading regulatory audits, operational transformation initiatives, and large-scale teams.
• Extensive knowledge of managed care claims administration and claims systems.
• Strong understanding of CMS and New York regulatory requirements.

Responsibilities

• Direct all medical, behavioral health, and delegated BPaaS claims operations.
• Oversee claims adjudication across all product lines for timeliness and accuracy.
• Provide executive‑level reporting and operational analysis to senior leadership.
• Lead enterprise‑wide projects involving claims operations, automation, and system modernization.
• Develop and execute strategic plans for the Claims organization.
• Sponsor major systems implementations and workflow redesign.
• Ensure compliance with CMS, NYS DoH, DFS, and accreditation requirements.
• Oversee recruitment, onboarding, performance management, and leadership development.

Skills

Leadership

Executive presence

Strategic thinking

Analytical skills

Communication

Education

Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or a related field

Master's degree in Business Administration, Health Administration, Public Health, or a related discipline preferred

Tools

Claims systems

Job description

MetroPlusHealth in New York is seeking a senior leader to oversee the Claims organization, acting as second-in-command to the VP of Claims. You will direct medical, behavioral health, and BPaaS operations, ensuring timely, compliant adjudication across all product lines.

This role requires extensive knowledge of managed care, CMS and NY regulations, and a track record of leading large teams through transformation.