Senior Director of Claims and Eligibility Operations

🔥 0 minutes ago

🌽 Illinois – Remote

🌽 Illinois – Remote

⏰ Full Time

🟠 Senior

⚙️ Operations

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Liviniti

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2011

🏥 Healthcare

⚕️ Healthcare Insurance

💊 Pharmaceuticals

Healthcare • Healthcare Insurance • Pharmaceuticals

Liviniti is a pass-through pharmacy benefit manager (PBM) that helps employers and health systems reduce prescription drug costs through transparent pricing, clinical programs, and drug sourcing. The company offers 100% rebate pass-through, a flat administrative fee, access to claims and rebate details for full visibility, customizable formularies and networks, prior authorization focused on lowest net cost, and specialized solutions like LivLite for managing GLP‑1 weight-loss drugs. Liviniti emphasizes B2B service, clinical value, and continuous innovation to lower pharmacy spend while maintaining member support and service.

📋 Description

• Own the strategic direction and operational performance of Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations • Serve as senior decision-making authority for claims and eligibility matters exceeding Director-level resolution capacity • Define operational standards, escalation frameworks, and performance benchmarks across functional areas • Represent Claims and Eligibility Operations in senior leadership discussions, cross-functional initiatives, and client-facing engagements • Partner with the VP of Operations and Sr. Director, Enterprise Operations on organizational strategy and platform priorities • Drive automation, AI-assisted workflows, and process improvement • Develop and maintain operational dashboards and KPI frameworks • Provide senior oversight of claims adjudication accuracy, timeliness, compliance, and continuous improvement • Set standards for benefit design accuracy and hold the Director of Claims Processing accountable for configuration quality • Drive the adjudication platform agenda with the technology team • Ensure claims operations are audit-ready and compliant with ERISA, state PBM transparency laws, applicable regulations, and NCPDP standards • Own the claims QA and testing framework • Provide senior oversight of eligibility data integrity, SLA performance, roadmap execution, and escalations • Serve as senior operational liaison to the technology team for platform issues, enhancements, deployments, and change control • Own operational readiness and continuity for platform changes • Collaborate with Compliance and Audit, downstream operations, and client stakeholders • Represent the function in finalist presentations and strategic client conversations • Provide strategic direction and senior oversight to the Directors of Claims Processing and Eligibility Operations • Own hiring decisions, performance standards, and talent development strategy across the domain • Maintain HIPAA compliance and report discovered violations

🎯 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 • Demonstrated experience in a transparent or pass-through PBM environment serving ERISA-qualified self-funded plans • 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 simultaneously, or at a comparable level of operational complexity • Proven track record of leading Director-level teams and driving measurable operational improvement across multiple functions • Experience building or overseeing a claims QA function within a PBM, health plan, or closely related healthcare environment • Experience managing operational continuity through technology implementations or significant system changes • Deep knowledge of PBM claims adjudication operations within a transparent or pass-through model, including ingredient cost pass-through pricing, dispensing fee structures, accumulator management, benefit design, and claims accuracy standards • Expert-level understanding of claims adjudication logic, including claim edit sequences, formulary and clinical edit interaction, plan design rule configuration, and systematic adjudication issue resolution at the engine level • Understanding of formulary management within the adjudication engine, including tier logic, step therapy, quantity limit enforcement, and prior authorization integration • Comprehensive knowledge of NCPDP adjudication transaction formats, including D.0 and F6 • Knowledge of NCPDP reject code management, Coordination of Benefits (COB) standards, and the NCPDP Data Dictionary • Expert understanding of eligibility operations including EDI standards (X12 834, 270/271), member enrollment workflows, and downstream claims impacts • Experience designing or overseeing claims QA programs, including testing protocols, sampling methodologies, and adjudication accuracy validation • Working proficiency in SQL and familiarity with cloud data platforms such as Snowflake, AWS, or Azure • Ability to translate operational requirements into platform specifications and hold technical partners accountable to delivery timelines • Ability to lead through two or more Director-level reports • Excellent written and verbal communication skills • High integrity, sound judgment, and discretion in handling PHI/PII and sensitive operational matters • Ability to thrive in a growth-stage environment • Ability to work core hours of 8:00 AM to 5:00 PM CT, with extended hours, weekends, and holidays as needed • Up to 20% travel • Preferred: familiarity with comparable claims adjudication and eligibility management platforms; product ownership, roadmap management, or business systems analysis; Jira, Zendesk, or Azure DevOps; URAC, NCQA, or SOC comparable operational compliance experience

🏖️ Benefits

• Medical, Dental and Vision insurance • Disability and Life insurance • Employee Assistance Program • Remote work options • Generous Paid-Time Off • Annual Reviews and Development Plans • Retirement Plan with company match immediately 100% vested