Gold Coast Health Plan

Operations

• 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, operational controls, and standard operating practices that promote consistency, quality, efficiency, and regulatory compliance.
• Represents Claims Execution in cross-functional committees, operational governance meetings, vendor meetings, regulatory discussions, and executive leadership forums.
• Identifies opportunities to improve provider and member experience by reducing operational defects, improving turnaround times, strengthening operational controls, and enhancing service delivery.
• Performs other duties as assigned.

Director, Operations – Claims Execution