Executive Director, Medicaid & Duals Claims Ops

CVS Health Corporation; Hartford (CT); On-site; USD 132,000 - 303,000; Full time

Benefits offered by this job

Bonus program

Equity awards

Job summary

CVS Health is seeking an Executive Director of Claims Service Operations to lead Medicaid and Duals claims across multiple markets. This role is responsible for delivering operational excellence, improving accuracy, timeliness, and provider/member experience, aligning with enterprise priorities.

You will partner with health plan, operations, technology, and compliance teams, drive automation, governance, workforce planning, and vendor management, and foster a culture of accountability and

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.

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 connecting performance, risk management, issue resolution and accountability.
• Advance automation and auto-adjudication strategies to improve cycle times and accuracy.
• Collaborate with technology teams to prioritize operational enhancements and system performance.
• Support AI-enabled capabilities by identifying use cases and defining business requirements.
• Develop workforce and capacity strategies including staffing models and budgeting.
• Lead vendor governance with scorecards, quality oversight, forecast, compliance controls.
• Drive continuous improvement reducing cost and rework while improving scalability.
• Build and develop high-performing teams fostering accountability and collaboration.

Skills

Executive leadership

Claims operations

Medicaid/Duals knowledge

Stakeholder collaboration

Automation & AI

Vendor governance

Regulatory compliance

Process improvement

Budgeting & workforce planning

Change management

Education

Bachelor's degree or equivalent experience

Tools

QNXT or comparable claims platforms

Job description

CVS Health is seeking an Executive Director of Claims Service Operations to lead Medicaid and Duals claims across multiple markets. This role is responsible for delivering operational excellence, improving accuracy, timeliness, and provider/member experience, aligning with enterprise priorities.

You will partner with health plan, operations, technology, and compliance teams, drive automation, governance, workforce planning, and vendor management, and foster a culture of accountability and