Director, Claims Operations
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Posted: 10/21/2026
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Posted: 10/21/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive expertise in healthcare claims operations, including claims processing, stop loss management, and automation initiatives. Proven ability to lead teams, drive quality improvements, and maintain compliance while managing vendor relationships and operational risks.
Highest-signal resume keywords
Healthcare Claims OperationsClaims Adjudication LogicProcess ImprovementTeam LeadershipRegulatory Compliance
About the role
Key responsibilities & impact- Lead Gravie's end-to-end claims operations across production processing, stop loss, support and appeals, and claims payments
- Own claims processing lifecycle accountability for throughput, quality, timeliness, auto-adjudication targets, and first-pass resolution
- Assess claims-processing error trends, identify root causes, and execute sustained quality improvements
- Own stop loss claims production, including adjudication, inventory management, quality oversight, and team performance
- Manage Claims Managers and a payments team through coaching, feedback, and career development
- Ensure accurate and timely claims payments meeting contractual, regulatory, prompt-payment, and network-partner requirements
- Champion claims automation and process improvement with Optimization, Product, Engineering, and Configuration teams
- Manage claims inventory, forecast volume and staffing needs, conduct reviews, and prevent backlog accumulation
- Serve as primary claims operations contact for Finance, Sales, Account Management, and Clinical teams
- Manage payment, recoupment, and claims-processing vendor relationships and performance
- Maintain compliance, financial controls, transparency, accuracy, and protection against fraud, credit balance risk, and other operational risks
Requirements
What you’ll need- Bachelor's degree or commensurate experience
- 8+ years of experience in healthcare claims operations, including production processing, stop loss, support and appeals, and claims payments
- 3+ years of experience leading managers and teams
- Strong working knowledge of claims adjudication logic, stop loss mechanics, coordination of benefits, subrogation, recoupment, and payment integrity fundamentals
- Experience identifying and driving automation and process improvement in manual-heavy environments
- Familiarity with claims platforms and EDI workflows
- Ability to establish decision rights, operating norms, escalation paths, cross-team communication protocols, and inventory management practices
- Ability to work with operational metrics, identify trends, and build quantitative cases for process or structural changes
- Current authorization to work in the United States
Benefits
Comp & perks- Alternative medicine coverage
- Flexible PTO
- Up to 16 weeks paid parental leave
- Paid holidays
- 401(k) program
- Transportation perks
- Education reimbursement
- 2 days of paid paw-ternity leave
- Equity
- Bonus
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingStop Loss ManagementQuality OversightInventory ManagementAutomation InitiativesOperational MetricsError Trend AnalysisPayment Integrity FundamentalsCross-Team CommunicationDecision Rights Establishment
Soft Skills
CoachingFeedbackCareer DevelopmentCommunication
Tools & Technologies
Claims PlatformsEDI Workflows
Industry Keywords
Claims PaymentsContractual RequirementsFraud ProtectionCredit Balance RiskOperational Risks