Director, Claims Operations

Hi, we’re Gravie. Our mission is to create health benefits that actually benefit small and midsize businesses and their employees. Our innovative benefit solutions and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way. A LITTLE MORE ABOUT THE ROLE: We're looking for a Director, Claims Operations to lead Gravie's end-to-end claims operations including production processing, stop loss, support and appeals, and claims payments. You'll manage day-to-day claims operations across all queues, lead a team of managers and individual contributors, drive process improvement and automation, build a high-accountability team culture, manage vendor relationships and performance, and ensure adherence to contractual and regulatory requirements. YOU WILL: - Claims Operations Leadership: Own the full claims processing lifecycle across first pass, adjustments, stop loss, support, appeals, and payments, with direct accountability for throughput, quality, and timeliness at every stage. Set and drive auto-adjudication performance targets and lead continuous improvement in first-pass resolution rates - Quality & Error Resolution: Assess trends in claims processing errors, identify systemic root causes, and develop and execute plans to drive resolution and sustained quality improvement. Partner with Claims Quality and Configuration teams to implement fixes and track the reduction of recurring errors over time - Stop Loss Claims Processing: Own the claims production side of stop loss end-to-end, including adjudication of stop loss-eligible claims, inventory management, quality oversight, and team performance. Serve as the primary claims operations partner to EDI for intake and routing, and to Configuration for system rules, enhancements, and processing issue resolution - Team Management: Directly manage a team of Claims Managers and a small payments team, providing coaching, performance feedback, and career development. Foster a culture of ownership, psychological safety, and continuous improvement. Partner with HR and the VP of Claims to define role scope, growth paths, and consistent performance expectations across the team - Claims Payment Execution: Ensure accurate and timely claims payment processes that meet Gravie's contractual and regulatory obligations, including state prompt payment and network partner requirements - Automation & Process Improvement: Champion automation within claims operations; identifying high-volume manual workflows as candidates for improvement, owning operational readiness and adoption of new automated processes, and partnering with Optimization, Product, Engineering, and Configuration on implementation. Lead the transition of stable operational workarounds into scalable, steady-state processes - Inventory Management: Maintain and continuously improve claims inventory management; tracking claims across all queues, partnering with VP of Claims and Finance to project future volume and staffing needs, owning a regular inventory review process, and escalating blockers proactively to prevent backlog accumulation - Cross-Functional Collaboration: Serve as the primary claims operations contact for Finance, Sales, Account Management, and Clinical teams. Ensure cross-functional partners have a clear point of contact for operational claims decisions, and that system or process changes affecting claims are communicated before they create downstream impact. Partner with Optimization on reporting and analytics needs and with Configuration on change communication protocols - Vendor & Partner Management: Manage operational relationships with payment, recoupment, and claims processing vendors, ensuring performance standards and contractual obligations are consistently met - Compliance: Ensure claims operations, payment, and recoupment processes meet all applicable regulatory standards and contractual requirements. Implement and maintain financial controls to drive transparency and accuracy, protect against fraud, credit balance risk, and other operational risk YOU BRING: - Bachelor's degree or commensurate experience - 8+ years of experience in healthcare claims operations, with direct exposure to production processing, stop loss, support and appeals, and claims payments - 3+ years of experience leading managers and teams, with a track record of building accountability-driven cultures through periods of organizational change - Strong working knowledge of claims adjudication logic, stop loss mechanics, coordination of benefits, subrogation, recoupment, and payment integrity fundamentals - Experience identifying and driving automation and process improvement in manual-heavy environments; familiarity with claims platforms and EDI workflows - Ability to establish clear decision rights and operating norms, including escalation paths, cross-team communication protocols, and inventory management practices - Comfortable working with operational metrics, identifying trends, and building the case for process or structural changes with quantitative support A LITTLE MORE ABOUT US: - We know healthcare. Our company was founded and is still led by industry veterans who have started and grown several market-leading companies in the space. - We have raised money from top tier investors who share the same long-term vision as we do of building an industry defining company that will endure over the long run. We are well capitalized. - Our clients love us. Customer satisfaction rates among employees using Gravie health plans consistently rank above 80% – nearly 40 points above the industry average. - Our culture is unique. We tend to be non-hierarchical, merit-driven, opinionated but kind people who thrive working in a high-performance, fast-paced environment. People at Gravie care deeply about making a positive impact in the lives of the people we serve. BENEFITS Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard health and wellness benefits, Gravie’s package includes alternative medicine coverage, flexible PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, transportation perks, education reimbursement, and 2 days of paid paw-ternity leave. JOB APPLICANTS If you apply for employment with Gravie, personal information collected via our applicant tracking vendor is subject to our standalone California Job Applicant Notice at Collection, accessible directly within the application workflow and separate from this Policy.