Director, Claims Operations

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We own our work with accountability, make data‑driven decisions, embrace continuous learning, and celebrate collaboration because success is a team sport. Our mission is to be there in the moments that matter most for our members and employees, creating a community of connected care where coordinated, quality service is the norm and every member feels valued.

The Director, Claims Operations oversees end‑to‑end claims functions, including claims processing, payment recovery, claim analysis, issue resolution, and provider appeals. A skilled people and operations leader, the Director ensures high‑quality, timely, and accurate service delivery for customers, members, and providers across all lines of business in a dynamic, growth‑oriented environment. The role holds accountability for operational performance, cost management, and quality outcomes while driving scalability and standardization to support geographic expansion and increasing complexity.

Key Accountabilities

• Claims Operations Oversight
• Design, implement, and continuously enhance controls and reporting across Claims Operations
• Own MBRs and executive‑level reporting, including ad hoc SLT requests
• Provide end‑to‑end oversight of claims processing from intake through adjudication and payment
• Own performance management across daily, monthly, and quarterly KPIs, ensuring controls and actions drive service, cost, productivity, and quality outcomes
• Partner cross‑functionally (Payment Integrity, Customer Service, EDI, Configuration, Finance, IT, Compliance/SIU, Markets) to ensure accurate, timely claims outcomes and alignment across a matrixed environment
• Build and lead a high‑performing organization, driving accountability, talent development, and engagement
• Drive operational excellence through issue resolution, root cause analysis, and continuous improvement across processes, policies, and technology to prevent recurrence and optimize end‑to‑end performance

Strategic Planning

• Continuously assess and optimize people, process, and technology to exceed key performance measures (e.g., accuracy, quality, timeliness)
• Identify and prioritize improvement opportunities with clearly defined success metrics
• Develop business cases for large‑scale initiatives and oversee execution against budget, timelines, and interdependencies
• Represent Claims Operations in governance forums and enterprise committees

Improvement and Implementation

• Lead implementation of strategic initiatives across people, process, and technology
• Execute changes supporting process improvements, new business integration, and measurable performance outcomes
• Define and execute an optimized workforce strategy, including BPO partnerships, to drive cost efficiency and scalability

Required Qualifications

• Bachelor's degree or equivalent experience in a related field
• 10+ years of work experience beyond degree in healthcare, health plans and/or claims operations
• 5+ years of people leadership experience
• Experience partnering cross‑functionally (e.g., Payment Integrity, Finance, IT, Compliance) to deliver end‑to‑end claims outcomes
• Strong track record of driving operational performance across service, cost, productivity, and quality metrics
• Strong analytical and problem‑solving capabilities with a focus on root cause analysis and continuous improvement

Preferred Qualifications

• Experience with claims platform system migration in a build environment
• Proved expertise in change management with the ability to lead through change
• Ability to manage people and process in a highly matrixed and complex organization

Location: Office role; requires onsite work average 3 days per week. Candidates near Minnetonka, MN or Madison, WI are preferred.

Salary: $113,400 – $194,400. Typical hiring range: $113,400 – $170,100. Salary placement depends on education, experience, certifications, role scope, internal equity, and market data. Incentive plan compensation may also apply. Total rewards include medical, dental, vision, PTO, holidays, paid volunteer time off, 401(k) contributions, caregiver services, and other benefits.

Internal Applicants: To be eligible, employees must have been in their current role for at least one year.

Recruiter: Stacey Manley

Eligibility to work in the US: No work visa sponsorship is offered. Candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and work eligibility.

We are an Equal Opportunity employer. All qualified candidates receive consideration for employment regardless of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.