Executive Director, Medicaid & Duals Claims Operations - Aetna

4062 Aetna Resources, LLC; Hartford (CT); On-site; USD 132,000 - 303,000; Full time

Benefits offered by this job

Bonus program

Equity awards

Comprehensive benefits

Job summary

CVS Health is seeking an Executive Director of Claims Service Operations to lead Medicaid and Duals across multiple markets. You will drive operational excellence, automate adjudication, and work with health plan leaders to align priorities and achieve strong performance.

The role requires strategic vision, executive communication, and the ability to manage vendor relationships in a complex, matrixed environment.

Qualifications

• 12+ years of healthcare operations, managed care, claims, or health plan experience.
• 2+ years leading direct / indirect employees and developing teams (100+)
• Strong knowledge of Medicaid, and/or Duals will be highly valued
• Proven ability to influence and collaborate across a highly matrixed organization.
• Innovative mind‑set and willingness to challenge the status quo
• Proven track record leading large-scale operations across multi-site, remote, and vendor‑supported environments
• Experience partnering effectively across operations, technology, compliance, finance, clinical, provider, and health plan organizations
• Strong executive communication, change leadership, and problem‑solving skills

Responsibilities

• Lead a large, multi-market claims operations organization supporting Medicaid and Duals business performance.
• Drive operational excellence across claims inventory, timeliness, quality, payment accuracy, productivity, and service level commitments.
• Partner with health plan leaders and enterprise stakeholders to align priorities, resolve operational challenges, and execute strategic initiatives.
• Establish governance routines that connect operational performance, risk management, issue resolution, and accountability for results.
• Advance automation and auto-adjudication strategies to improve cycle times, reduce manual intervention, and increase processing accuracy.
• Partner closely with technology teams to prioritize operational enhancements, improve system performance, and support business-driven transformation initiatives.
• Support AI-enabled operational capabilities by identifying high-value use cases, defining business requirements, and improving quality and productivity outcomes.
• Develop workforce and capacity strategies, including staffing models, resource planning, budgeting, and vendor optimization.
• Lead vendor governance through performance scorecards, quality oversight, forecasting, compliance controls, and operational accountability.
• Drive continuous improvement initiatives that reduce cost, minimize rework, improve scalability, and strengthen end-to-end claims performance.
• Build and develop high-performing teams while fostering a culture of accountability, collaboration, innovation, and execution.

Skills

Executive leadership

Change leadership

Operational excellence

Strategic collaboration

Problem solving

Education

Bachelor's degree or equivalent experience

Tools

QNXT

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Aetna is seeking to hire an Executive Director of Claims Service Operations supporting Medicaid and Duals businesses. This role is accountable for delivering operational excellence across a large-scale, complex environment, with responsibility for claims performance, regulatory execution, automation advancement, vendor governance, workforce strategy, and shared services alignment. The successful leader will partner across health plan, operations, technology, clinical, compliance, and enterprise functions to translate strategic priorities into disciplined operational execution. This individual will drive improvements in claims accuracy, productivity, service performance, and payment integrity while reducing rework, strengthening controls, and enhancing the provider and member experience.

Key Responsibilities

• Lead a large, multi-market claims operations organization supporting Medicaid and Duals business performance.
• Drive operational excellence across claims inventory, timeliness, quality, payment accuracy, productivity, and service level commitments.
• Partner with health plan leaders and enterprise stakeholders to align priorities, resolve operational challenges, and execute strategic initiatives.
• Establish governance routines that connect operational performance, risk management, issue resolution, and accountability for results.
• Advance automation and auto-adjudication strategies to improve cycle times, reduce manual intervention, and increase processing accuracy.
• Partner closely with technology teams to prioritize operational enhancements, improve system performance, and support business-driven transformation initiatives.
• Support AI-enabled operational capabilities by identifying high-value use cases, defining business requirements, and improving quality and productivity outcomes.
• Develop workforce and capacity strategies, including staffing models, resource planning, budgeting, and vendor optimization.
• Lead vendor governance through performance scorecards, quality oversight, forecasting, compliance controls, and operational accountability.
• Drive continuous improvement initiatives that reduce cost, minimize rework, improve scalability, and strengthen end-to-end claims performance.
• Build and develop high-performing teams while fostering a culture of accountability, collaboration, innovation, and execution.

Qualifications

• 12+ years of healthcare operations, managed care, claims, or health plan experience.
• 2+ years leading direct / indirect employees and developing teams (100+)
• Strong knowledge of Medicaid, and/or Duals will be highly valued
• Proven ability to influence and collaborate across a highly matrixed organization.
• Innovative mind‑set.
• Willing to challenge the status quo.
• Proven track record leading large-scale operations across multi-site, remote, and vendor‑supported environments.
• Strong knowledge of claims operations, regulatory requirements, and operational performance management.
• Demonstrated success driving process improvement, automation, and operational transformation initiatives.
• Experience partnering effectively across operations, technology, compliance, finance, clinical, provider, and health plan organizations.
• Strong executive communication, change leadership, and problem‑solving skills.
• Proven ability to influence and collaborate across a highly matrixed organization.
• Innovative mindset with a focus on driving operational efficiency and continuous improvement.
• Strong people leader with a track record of developing talent, holding teams accountable, and navigating difficult conversations.
• Ability to thrive in a fast‑paced environment and lead effectively through ambiguity.

Preferred Qualifications

• Experience leading shared services operations within a complex matrixed organization.
• Experience with auto‑adjudication, AI‑enabled operations, or digital transformation initiatives.
• Background in workforce planning, budgeting, and capacity optimization.
• Experience with QNXT or comparable claims platforms preferred.

Education

Bachelor's degree or equivalent experience.

Pay Range

The typical pay range for this role is: $131,500.00 - $303,195.00 This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.

Benefits

• Medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 10/26/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Our Work Experience is the combination of everything that’s unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it’s our people. Our employees are self‑disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.