• Manage and develop a team of Claims and Appeals Processors, providing training, feedback, and performance management to ensure SLA and quality targets are consistently met • Own end-to-end claims operations, including adjudication, appeals, QA, IDR negotiations, and compliance with plan policies and regulatory requirements • Develop and strengthen scalable processes by documenting SOPs, identifying workflow improvements, and leading automation or tooling initiatives that reduce friction and improve accuracy • Manage customer support and provider escalations, partnering closely with CX, Network Operations, Sales, and Broker teams to resolve issues efficiently and represent Claims Operations with professionalism and clarity • Oversee rule-based payment logic, collaborating with Product and Engineering to maintain and enhance our claims rules engine and operational systems (Jira, internal platforms, reporting tools, etc.) • Build and maintain plan document infrastructure ensuring operational accuracy, alignment with claims logic and network rules, and regulatory compliance • Serve as claims subject-matter expert for internal teams, manage vendor relationships, and ensure timely support for Stop Loss reporting and required documentation. • Develop KPIs and reporting dashboards to monitor performance, uncover trends, and drive continuous operational improvement • Partner on payment integrity and cost containment programs, leveraging data and vendor partnerships to reduce waste, ensure appropriate reimbursement, and protect plan assets • Drive cross-functional projects, coordinating requirements, timelines, and stakeholders for system changes, rule updates, plan documents, and process improvements