Overview

Job Description Job Description: Senior Director of Claims and Eligibility Operations - REMOTE Role And Responsibilities The Senior Director of Claims and Eligibility Operations is responsible for the strategic leadership and operational oversight of two critical and interdependent functions within Liviniti's Operations organization: Claims Adjudication and Eligibility Operations. This is a senior leadership role that carries accountability for the accuracy, integrity, and performance of both verticals, and serves as the primary operational and technical authority bridging platform capability with day-to-day execution. The Sr. Director leads a multi-functional domain that includes Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations. The Sr. Director maintains ultimate accountability for the performance and strategic direction of the full domain and is expected to engage the technology team as a peer, represent these functions at the senior leadership level, and drive continuous improvement across the claims and eligibility ecosystem. The Sr. Director of Claims and Eligibility Operations is required to perform, but not limited to, the following responsibilities: Strategic Leadership And Domain Ownership • Own the strategic direction and operational performance of Claims Adjudication, Claims Quality Assurance and Testing, and Eligibility Operations, ensuring each area has clear goals, accountable leadership, and the resources needed to execute • Serve as the senior decision-making authority for claims and eligibility matters that exceed Director-level resolution capacity • Define and maintain operational standards, escalation frameworks, and performance benchmarks across all functional areas • Represent Claims and Eligibility Operations in senior leadership discussions, cross-functional initiatives, and client-facing engagements, including conversations where full claims cost and adjudication transparency is expected by the client • Partner with the VP of Operations and Sr. Director, Enterprise Operations on org-wide strategy and platform priorities • Identify and pursue opportunities for automation, AI-assisted workflows, and process improvement across claims and eligibility operations • Own the development and maintenance of operational dashboards and KPI frameworks across all functional areas, ensuring decisions are data-driven and leadership has consistent visibility into claims accuracy, eligibility performance, QA outcomes, and key operational metrics on a regular reporting cadence • Operate as an enterprise leader, not just a functional one proactively identifying cross-functional risks and contributing to company-wide priorities beyond the claims and eligibility domain Claims Adjudication Oversight • Provide senior oversight of the claims adjudication function, ensuring accuracy, timeliness, and compliance with client contractual obligations and regulatory requirements • Own accountability for adjudication quality metrics and continuous improvement plans, driving measurable gains in claims accuracy and processing performance • Set the standard for benefit design accuracy and hold the Director of Claims Processing accountable for configuration quality across all client populations • Drive the adjudication platform agenda with the technology team, setting priorities for enhancements and holding technical partners accountable to production stability standards • Ensure claims operations are audit-ready and compliant with ERISA, state PBM transparency laws, and applicable regulatory standards, including pass-through pricing validation and ingredient cost accuracy • Ensure claims adjudication operations maintain compliance with current NCPDP standards and are positioned to support ongoing standard transitions as they are adopted across the industry, including D.0 to F6 • Own the claims QA and testing framework, ensuring systematic validation of adjudication accura