GuideWell Source is part of the GuideWell Family and works across healthcare delivery, healthcare insurance, and consulting. The company develops and brings healthcare solutions to market, including care models designed to improve patient outcomes and strengthen consumer engagement. Its services also include administrative and claims processing support for state and federal Medicare and Medicaid programs, helping health organizations manage complex operations with a focus on reliability and operational excellence.
Senior Director of Business Rule Modernization
GuideWell Source’s Senior Director will modernize claims adjudication rules across fragmented platforms. The role leads governance, AI-enabled automation, and accuracy efforts for Florida Blue’s health plan transformation.
Description
- Set modernization priorities in line with the Core Admin Platform transformation, executive goals, and adjudication accuracy standards.
- Assess adjudication rules continuously across all lines of business.
- Create a unified rules registry and inventory spanning five platforms with fragmented logic.
- Review rule configurations with IT partners to identify inaccuracies, duplication, and conflicts.
- Assign and document clear business ownership for every rule.
- Rank rule gaps by risk, cost, and effects on members and providers.
- Oversee the design and rollout of updated rule configurations.
- Consolidate fragmented rule logic into a single governed source.
- Find and implement low-code and AI tools to automate rule configuration and upkeep.
- Set shared objectives and accountability with business units and IT.
- Build ongoing governance and oversight to maintain rule accuracy and performance.
- Track and report the efficiency and accuracy of adjudication rule systems and processes.
- Identify rule drift and emerging risks for remediation.
- Ensure monitoring supports accurate, auditable operations that meet corporate policy, regulatory standards, and accrediting criteria.
- Connect senior business leaders with the technical team that enables the work.
- Keep programs aligned with the enterprise AI Coalition strategy.
- Manage a team of Senior Consultants.
Requirements
- At least 10 years of related experience, including direct work with claims adjudication, business rule configuration, or rules engine management.
- Strong subject matter expertise in claims adjudication rules, including configuration, rules engines, and downstream code management.
- Experience using a structured approach, such as Assess, Improve, and Monitor, to evaluate and modernize complex rule sets.
- Experience identifying and implementing low-code and AI-enabled automation to reduce manual configuration and reconciliation.
- Strategic planning and organizational skills, with the ability to work through ambiguity.
- Excellent written and verbal communication skills.
- Strong critical thinking skills to assess options and recommend solutions aligned with business objectives and strategy.
- Experience with project management concepts, methods, and processes.
- Ability to manage people, budgets, and information.
- Ability to establish, implement, and manage effective workflows and organizational structures.
- Ability to contribute to and influence business plans and strategies.
- Knowledge of the systems development life cycle.
- At least five years of direct supervisory or management experience.
- Bachelor’s degree or equivalent additional related work experience.
- Ability to travel to multiple work locations.
Benefits
- Medical, dental, vision, life, and global travel health insurance.
- Short- and long-term disability programs.
- Leave programs for personal circumstances.
- Retirement Savings Plan with an employer match.
- Paid time off.
- Volunteer time off.
- Ten holidays.
- Two well-being days.
- Additional voluntary benefits.
- Comprehensive wellness program.
- Potential incentive or commission compensation.
- Annual pay-for-performance reviews with the possibility of base pay increases.