Remote Senior Director - Claims & Eligibility Ops

Southern-Scripts-LLC; Chicago (IL); Remote; USD 180,000 - 240,000; Full time

Job summary

Southern Scripts is seeking a Senior Director of Claims and Eligibility Operations to lead two critical functions—Claims Adjudication and Eligibility Operations—across remote, national coverage. This role drives strategic direction, oversees QA and testing, and ensures compliance with ERISA and regulatory standards while partnering with technology teams.

The position requires deep PBM expertise, strong leadership of Director-level teams, and a track record of delivering operational improvements

Qualifications

• Bachelor's degree required (Healthcare Administration, Business, Information Systems, or related field).
• 10+ years of progressive PBM claims operations, eligibility management, or related leadership.
• Experience in a transparent or pass-through PBM environment serving ERISA-qualified self-funded plans.
• Knowledge of ERISA fiduciary obligations, self-funded plan administration, and related regulatory requirements.
• Experience leading claims adjudication, QA, and eligibility functions at a senior level.
• Proven track record of directing Director-level teams and driving operational improvements.
• Experience building or overseeing a claims QA function within PBM/health plans.
• Experience managing continuity through technology implementations or major system changes.

Responsibilities

• Own strategic direction and operational performance of Claims Adjudication, QA, and Eligibility Operations.
• Serve as senior decision-maker for claims and eligibility matters beyond Director level.
• Define and maintain standards, escalation frameworks, and performance benchmarks.
• Represent Claims and Eligibility Operations in senior leadership and client discussions.
• Partner with the VP of Operations on org-wide strategy and platform priorities.
• Identify opportunities for automation, AI-assisted workflows, and process improvements.
• Develop and maintain dashboards and KPI frameworks for visibility.
• Ensure platform changes are deployed with minimal disruption and proper contingency plans.
• Collaborate with technology teams on platform readiness and deployment governance.
• Lead cross-functional efforts to align operations with client needs and enterprise goals.

Skills

PBM claims adjudication

Adjudication logic

Formulary management

NCPDP standards

Eligibility operations

SQL

Cloud data platforms

Stakeholder communication

PHI handling

Education

Bachelor's degree

Tools

Jira

Zendesk

Azure DevOps

Job description

Southern Scripts is seeking a Senior Director of Claims and Eligibility Operations to lead two critical functions—Claims Adjudication and Eligibility Operations—across remote, national coverage. This role drives strategic direction, oversees QA and testing, and ensures compliance with ERISA and regulatory standards while partnering with technology teams.

The position requires deep PBM expertise, strong leadership of Director-level teams, and a track record of delivering operational improvements