Director Operations, Claims Execution

Come Grow With Us At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges. Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met.

We are seeking collaborators, innovators, and those who are driven to be their very best. If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily.

Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

This role is open to California residents only.

• Provides strategic and operational leadership for the Claims Execution organization, ensuring the timely, accurate, compliant, and cost-effective execution of all operational work performed within Claims Operations.
• Directs the day-to-day management of operational work queues including operational intake, complex claims processing, provider dispute resolution (PDR), encounter operations, adjustments and reprocessing, member reimbursements, correspondence management, check run operations, and other assigned operational functions.
• Serves as the department subject matter expert in operational inventory management, workload prioritization, capacity planning, queue governance, aging management, and operational performance.
• Establishes and maintains operational standards, workflows, service level expectations, and performance metrics to ensure consistent execution and effective inventory management across all Claims Execution functions.
• Provides operational oversight and performance management of the Business Process Outsourcing (BPO) claims processing vendor, including production performance, quality, inventory management, turnaround times, service level agreement compliance, issue resolution, and continuous operational improvement.
• Monitors operational inventories, identifies emerging risks, capacity constraints, backlog trends, and aging work items, and implements corrective actions to maintain operational performance and regulatory compliance.
• Leads, develops, coaches, and evaluates management and staff within Claims Execution, fostering a culture of accountability, operational excellence, continuous improvement, and customer service.
• Establishes operational priorities and allocates resources to ensure workloads are balanced, service levels are achieved, and organizational priorities are effectively executed.
• Partners with Claims Business Operations to identify operational defects, workflow inefficiencies, automation opportunities, and business improvement initiatives that improve operational performance and reduce manual work.
• Collaborates with Configuration, Information Technology, Finance, Compliance, Provider Network Operations, Payment Integrity, Customer Service, and other internal and external business partners to resolve operational issues and support enterprise initiatives.
• Ensures compliance with all applicable federal and state regulatory requirements, contractual obligations, organizational policies, and operational standards governing Claims Operations.
• Oversees operational readiness and implementation of new regulatory requirements, business initiatives, products, systems, and organizational changes impacting Claims Execution.
• Monitors departmental performance through key performance indicators, operational dashboards, inventory metrics, quality measures, and service level reporting, taking corrective action as necessary to achieve operational goals.
• Develops and maintains departmental procedures,…