• Provides strategic and operational leadership for the Complex Claim Unit (CCU) nursing teams • Coaches and develops Health Services Managers • Responds to internal and external inquiries • Ensures compliance with regulatory and accreditation standards • Partners across business units to support enterprise initiatives • Plans, organizes, and manages resources and processes to achieve program objectives • Oversees utilization, clinical, and billing claim reviews • Implements and monitors clinical edits and payment integrity programs • Develops, prioritizes, and executes medical cost containment initiatives • Identifies, recommends, and implements best practices to optimize operational efficiency • Establishes departmental goals aligned with functional and enterprise strategies • Defines, monitors, and reports key production, quality, and financial performance metrics • Collaborates with Network Analytics, Coverage Policy, and Medical Directors to identify and implement savings • Provides subject-matter expertise and representation for Legal and Client Services related to clinical prepay programs • Evaluates and develops Health Services Managers • Leads automation, process improvement, and change initiatives • Manages workforce planning, capacity modeling, and financial forecasting • Ensures compliance with internal policies and product standards • Conducts performance evaluations and manages compensation-related processes • Leverages data analytics and business process engineering to drive continuous improvement • Participates in Payment Integrity initiatives and other assigned projects