Director, Claims Process Optimization – Facets Required

CareSource

. Lead the design, implementation, and ongoing oversight of automation and artificial intelligence capabilities across claims operations .

Posted 10/12/2026full-timeRemote • United StatesLead💰 $113,000 - $197,700 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in leading automation and artificial intelligence initiatives within claims operations, with a strong focus on performance metrics, budget management, and vendor oversight. Possesses a solid foundation in claims adjudication processes and the ability to communicate complex information effectively to executive stakeholders.

Highest-signal resume keywords

Claims Operations LeadershipAutomation and Artificial Intelligence ImplementationClaims Adjudication KnowledgeFinancial AcumenAnalytical Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AdjudicationAutomation CapabilitiesProcess MappingData AnalysisBudget ManagementRoot Cause AnalysisPerformance MetricsBusiness Case DevelopmentRegulatory ComplianceVendor Management

Soft Skills

Change LeadershipClear CommunicationTeam LeadershipProblem SolvingCollaboration

Industry Keywords

Healthcare OperationsHealth Plan ClaimsCPTHCPCSICD-10Revenue CodesOperational RiskQuality StandardsService LevelsProduction Performance

About the role

Key responsibilities & impact

Lead the design, implementation, and ongoing oversight of automation and artificial intelligence capabilities across claims operations
Identify opportunities for intelligent automation, build business cases, guide delivery with configuration, information technology, and vendor partners, and validate sustained production performance
Maintain oversight of claims adjudication and adjustment workflows
Monitor the operating budget and manage vendor performance
Lead a team of managers, analysts, and process specialists
Own operating performance, including inventory, throughput, auto-adjudication rate, accuracy, and regulatory turnaround time
Build and maintain the claims automation and artificial intelligence roadmap
Quantify and report benefit realization against pre-deployment baselines
Analyze workflows using process mapping, time studies, and production data
Build business cases for automation and improvement investments and report actual performance
Track cost per claim and capacity utilization to inform staffing, sourcing, and automation sequencing
Develop and monitor operating budgets for assigned functions and technology initiatives
Direct root cause analysis and resolution of recurring defects with upstream owners
Maintain procedures, process controls, and audit evidence for internal, state, federal, and delegated reviews
Run daily production reviews, weekly operating reviews, and monthly business reviews
Manage outsourced, offshore, and technology vendors against service levels, quality standards, and delivery commitments
Participate in vendor selection, statement of work development, and renewal decisions
Perform other job-related duties as requested

Requirements

What you’ll need

Bachelor's degree in business, health administration, data analytics, or a related field required
Equivalent years of relevant work experience may be accepted in lieu of required education
Seven (7) years of health plan claims or healthcare operations experience required
Five (5) years of leadership experience required
Practical understanding of automation and artificial intelligence capabilities applicable to claims work
Working knowledge of claims adjudication platforms, provider reimbursement methodologies, and standard code sets including CPT, HCPCS, ICD-10, and revenue codes
Strong analytical skills
Proven change leadership skills
Strong financial acumen
Clear written and verbal communication, including the ability to present technical detail and operational risk to executive audiences
General office environment; may be required to sit or stand for extended periods of time
Travel is not typically required

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Comprehensive total rewards package
Employee total well-being support
Remote work arrangement