Director, Business Systems Claims Implementation

• Lead end-to-end implementations and enhancements of healthcare claims systems (Facets, HealthAxis, or similar)
• Oversee provider operations, including credentialing, provider data management, and network configuration
• Drive benefit configuration, pricing methodologies, and claims adjudication optimization
• Partner with business and IT teams to deliver system integrations (EDI, vendor systems, APIs)
• Lead UAT cycles, system releases, and production deployments
• Ensure compliance with CMS, NCQA, HIPAA, and other regulatory standards
• Identify opportunities to improve auto-adjudication rates and reduce manual claims processing
• Manage and mentor cross-functional teams (20+ resources) across operations and systems
• Develop and implement policies, procedures, and governance frameworks
• Collaborate with executive leadership on strategic planning, budgeting, and roadmap development

• 10+ years of experience in the healthcare payer operations and overseeing the implementation of those systems
• Strong expertise in:
• Claims systems (Facets, HealthAxis, or similar)
• Provider operations and credentialing
• Benefit configuration and pricing methodologies
• Experience working within Medicare Advantage / Managed Care environments
• Proven track record of leading system implementations and integrations
• Strong understanding of CMS, NCQA, and regulatory compliance requirements
• Experience managing large teams and cross-functional stakeholders
• Excellent communication and leadership skills

Preferred Qualifications

• Experience with:
• EDI transactions (837, 835, etc.)
• Provider data platforms and credentialing systems (eVips, CAQH, Quest Analytics)
• Claims auto-adjudication optimization
• Background in healthcare digital transformation or modernization initiatives
• Experience working with startups or high-growth healthcare organizations
• PMP or similar leadership certification

We are seeking a Director / Senior Manager of Healthcare Systems & Provider Operations to lead strategic initiatives across claims systems, provider data, credentialing, and benefit configuration. This role will drive system implementations, operational efficiency, and regulatory compliance within a payer environment. The ideal candidate brings deep expertise in claims platforms, provider operations, and Medicare Advantage, along with strong leadership experience managing cross-functional teams and large-scale system initiatives.