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CareSource
CareSource
1,001 – 5,000 Employees
H1B Visa SponsorHealthcareHealthcare InsuranceInsurance
CareSource is a healthcare insurance company serving members through Medicaid, Marketplace, and Medicare Advantage plans. Its coverage and support services are designed for groups including low-income adults and families, children, pregnant women, older adults, and people with disabilities. CareSource also provides dental, vision, hearing, pharmacy, and COVID-19 support resources, with online and mobile tools that help members manage their healthcare.
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CareSource Director of Claims Process Optimization (Facets)

Lead claims optimization at CareSource, advancing automation and AI across health plan operations. Improve adjudication, financial results, vendor performance, and regulatory readiness.

USUnited States
$113,000 – $197,700 / year
RemoteFull-timeLeadEnglish RequiredDirector

Description

  • Lead automation and AI initiatives across claims operations, from design through ongoing oversight.
  • Spot opportunities for intelligent automation, develop business cases, coordinate delivery with configuration, IT, and vendor partners, and verify lasting production results.
  • Oversee claims adjudication and adjustment workflows.
  • Monitor operating budgets and vendor performance.
  • Manage managers, analysts, and process specialists.
  • Account for operating results, including inventory, throughput, auto-adjudication, accuracy, and regulatory turnaround times.
  • Develop and maintain the claims automation and AI roadmap.
  • Measure and report realized benefits against pre-launch baselines.
  • Assess workflows through process maps, time studies, and production data.
  • Make the case for automation and process improvement investments, then report actual results.
  • Monitor cost per claim and capacity use to guide staffing, sourcing, and automation priorities.
  • Set and track budgets for assigned functions and technology initiatives.
  • Lead root cause investigations and work with upstream owners to resolve recurring defects.
  • Maintain procedures, controls, and audit evidence for internal, state, federal, and delegated reviews.
  • Lead daily production, weekly operations, and monthly business reviews.
  • Oversee outsourced, offshore, and technology vendors against service levels, quality requirements, and delivery commitments.
  • Contribute to vendor selection, statements of work, and renewal decisions.
  • Handle other job-related duties as assigned.

Requirements

  • Bachelor's degree in business, health administration, data analytics, or a related field; equivalent relevant work experience may substitute.
  • At least seven years of experience in health plan claims or healthcare operations.
  • At least five years of leadership experience.
  • Practical knowledge of automation and AI applications for claims operations.
  • Working knowledge of claims adjudication platforms, provider reimbursement methods, and coding standards such as CPT, HCPCS, ICD-10, and revenue codes.
  • Strong analytical ability.
  • Demonstrated skill in leading change.
  • Strong financial judgment.
  • Clear written and verbal communication, including presenting technical details and operational risks to executives.
  • Work in a general office setting and be able to sit or stand for extended periods.
  • Travel is generally not required.
  • Salary range of $113,000–$197,700 per year.

Benefits

  • May be eligible for a bonus based on company and individual performance.
  • Comprehensive total rewards package.
  • Support for employee well-being.
  • Remote work arrangement.

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