Director I Claims

• Providing a broad range of services needed by policy owners/clients and filed force to maintain in-force policies or new business
• Develops/implements complaint resolution procedures
• Develops short/long-term customer service objectives and continuously monitors procedures to ensure these are met by staff
• Ensures area is staffed and trained to handle inquiries from agents and policy owners
• Stays abreast of state and federal regulations and their impact on the industry
• Hires, trains, coaches, counsels and evaluates performance of direct reports
• Provide strategic and operational leadership across Medicare and Medicaid claims, including first-time claim processing, post-pay adjustments, corrected claims, provider inquiries, written correspondence, escalations, and mass-adjustment or sweep activity.
• Establish and maintain a management system that consistently meets or exceeds service-level agreements, prompt-pay requirements, performance guarantees, quality standards, inventory targets, and regulatory commitments.
• Use deep knowledge of Medicare and Medicaid policies, state and federal requirements, benefit and reimbursement rules, claims platforms, and operational workflows to guide complex claim decisions and resolve systemic issues.
• Own audit readiness and response for the assigned operation, including control design, evidence production, issue remediation, corrective action planning, and sustained monitoring of regulatory, client, internal, and external audit findings.
• Partner closely with technology, digital, analytics, payment integrity, provider operations, finance, compliance, audit, market, and vendor teams to deliver integrated solutions and remove barriers to operational performance.
• Build and maintain performance visibility through actionable metrics, trend analysis, capacity and demand planning, risk indicators, and executive-level reporting that clearly identifies drivers, decisions, and corrective actions.
• Ensure staffing, workflow allocation, training, documentation, and leadership routines are sufficient to manage changing volumes, regulatory requirements, and business priorities without compromising service or quality.
• Lead, develop, and hold accountable a multi-level organization; strengthen succession and talent pipelines while creating a culture of ownership, continuous improvement, regulatory discipline, and customer focus.

• Requires a BA/BS and 7 years leadership experience; or any combination of education and experience which would provide an equivalent background.

• Extensive leadership experience in health plan claims operations with direct responsibility for both Medicare and Medicaid lines of business.
• Demonstrated experience leading or serving as the operational point person for a claims automation initiative with measured impact to efficiency, productivity, capacity, quality, cost, or cycle time.
• Experience developing business requirements, partnering with technology and digital teams, supporting testing and implementation, managing operational readiness and adoption, and validating post-implementation benefits.
• Executive-level communication and cross-functional influence skills, with the ability to translate complex regulatory and operational issues into clear decisions, actions, and accountability.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact View email address on us.fitly.work for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act