GuideWell Source je del skupine GuideWell Family in deluje na področjih zagotavljanja zdravstvene oskrbe, zdravstvenega zavarovanja in svetovanja. Podjetje razvija zdravstvene rešitve in jih uvaja na trg, vključno z modeli oskrbe, zasnovanimi za izboljšanje izidov zdravljenja pacientov in krepitev vključenosti uporabnikov. Njegove storitve vključujejo tudi administrativno podporo in obdelavo zahtevkov za državne in zvezne programa Medicare in Medicaid, s čimer zdravstvenim organizacijam pomaga upravljati zapletene postopke s poudarkom na zanesljivosti in operativni odličnosti.
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.
Združene države Amerike
Florida152.000 $ – 247.000 $ / leto
HibridnoPolni delovni časSeniorZahtevani Jezik: angleščinaDirektorOpis
- 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.
Zahteve
- 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.
Ugodnosti
- 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.