Director of Operations - REMOTE

Responsibilities

• Own day-to-day operational execution across ASO, Fully Insured, ACA, and Stop-Loss lines of business.
• Ensure operational teams deliver accurate, timely, compliant, and high-quality services.
• Establish accountability across teams for service levels, productivity, quality, turnaround times, and client commitments.
• Manage operational priorities, workload capacity, resource allocation, and business performance.
• Ensure operational consistency across lines of business while managing the unique requirements of self-funded ASO administration, Fully Insured plan operations, ACA workflows, and stop-loss administration.
• Identify operational risks and opportunities while implementing solutions to improve performance, reliability, and client experience.
• Oversee execution of claims administration, eligibility coordination, billing support, stop-loss administration, carrier collaboration, recoveries, and operational controls.
• Ensure claims and operational processes meet quality, compliance, financial, and service expectations.
• Monitor claims and stop-loss performance, identify challenges, and implement corrective actions.
• Partner with internal teams and external stakeholders to resolve operational issues and improve outcomes.
• People Leadership & Organizational Development
• Recruit, develop, coach, and retain high-performing operational teams and leaders.
• Establish clear performance expectations, leadership capabilities, and professional development opportunities.
• Build a culture of accountability, collaboration, continuous improvement, and customer-focused execution.
• Develop organizational capacity to support business growth and evolving operational needs.
• Lead managers and teams through operational changes while ensuring engagement and adoption.
• Operational Performance Management
• Establish and manage operational KPIs, SLAs, quality standards, productivity measures, and service performance goals.
• Monitor operational results and implement improvement plans when performance expectations are not met.
• Maintain visibility into operational trends, risks, opportunities, and business outcomes.
• Provide leadership with insights and recommendations to improve operational effectiveness.
• Process Improvement & Operational Optimization
• Help identify opportunities to improve operational efficiency, reduce complexity, and enhance service delivery.
• Ensure operational teams successfully adopt and sustain new processes, technologies, and operating practices.
• Support continuous improvement efforts by identifying root causes, improving workflows, and strengthening operational discipline.
• Compliance & Operational Governance
• Ensure compliance with applicable federal and state regulations, contractual obligations, internal policies, and healthcare industry requirements.
• Support audit readiness, quality assurance programs, and operational governance activities.
• Maintain appropriate operational controls and risk management practices.
• Ensure teams operate within established compliance and quality standards.
• Cross-Functional Partnership
• Partner with Technology, Finance, Compliance, Client Success, Implementation, Transformation, and Executive Leadership to resolve operational issues and support business objectives.
• Work on initiatives involving process improvement, automation, technology enablement, and organizational change.
• Communicate operational performance, priorities, risks, and recommendations to executive leadership.
• Translate business strategy into effective operational execution.

  Qualifications

  • Significant leadership experience within a third-party administrator (TPA), self-funded health plan, managed care, or health insurance environment.
  • Deep knowledge of claims administration, stop-loss operations, healthcare operations, and employer-sponsored health plans.
  • Demonstrated success leading complex healthcare operations with responsibility for service delivery, team performance, operational metrics, and organizational growth.
  • Experience managing operational teams, workforce planning, and performance improvement initiatives.
  • Proven ability to establish accountability, improve service delivery, and scale operational capabilities.
  • Strong understanding of claims adjudication, eligibility, enrollment, billing operations, EDI transactions, stop-loss administration, and self-funded health plan processes.
  • Experience supporting ACA, Fully Insured, ASO, and stop-loss operations.
  • Working knowledge of stop-loss administration, including specific and aggregate recovery processes.
  • Technology & Analytics Experience
  • Using claims administration platforms, workflow tools, operational reporting, dashboards, and analytics to improve operational outcomes.
  • Ability to partner effectively with Technology and Transformation teams to implement operational improvements.
  • Experience using data and performance metrics to identify opportunities and drive accountability.
  • Leadership & Communication
  • Strong leadership, communication, and stakeholder management skills.
  • Ability to develop teams, influence partners, solve complex operational challenges, and communicate effectively with executive leadership.
  • Ability to translate operational strategy into execution while collaborating across functions.