Senior Director of Claims and Eligibility Operations - REMOTE
Liviniti · United States · 2 days ago
RemoteRemoteSalesFull-time
And Responsibilities
- Strategic Leadership And Domain Ownership
- Provide senior oversight of the claims adjudication function
- Provide senior oversight of the eligibility function
- Platform And Technology Partnership
- Cross-Functional Leadership And Client Support
- Team Leadership And Development
Required Skills And Competencies
- Deep knowledge of PBM claims adjudication operations
- Expert-level understanding of claims adjudication logic
- Comprehensive knowledge of NCPDP adjudication transaction formats
- Deep working knowledge of NCPDP reject code management
- Comprehensive knowledge of NCPDP Data Dictionary
- Comprehensive knowledge of Coordination of Benefits (COB) standards
- Comprehensive knowledge of EDI standards
- Expert understanding of eligibility operations
- Strong technical orientation with working proficiency in SQL
- Proven ability to engage the technology team as a peer
- Experience managing operational continuity through technology implementations or significant system changes
- Demonstrated ability to lead through two or more Director-level reports
- Excellent written and verbal communication skills
- High integrity, sound judgment, and demonstrated discretion in handling PHI/PII and sensitive operational matters
Qualifications And Education Requirements
- Bachelor's degree required (Healthcare Administration, Business, Information Systems, or related field)
- 10 or more years of progressive experience in PBM claims operations, eligibility management, or closely related healthcare operations leadership
- Working knowledge of ERISA fiduciary obligations, self-funded plan administration, and associated regulatory requirements relevant to pharmacy benefit management
- Demonstrated experience owning or providing senior leadership over claims adjudication, quality assurance, and eligibility functions