Director, Claims Policy and Governance

Description

Position Purpose: Leads the development, maintenance, and governance of enterprise claims policies and related operational documentation. This role establishes and maintains governance frameworks, documentation standards, and policy lifecycle processes that promote consistent and compliant claims administration across applicable products, markets, and platforms. Partners with Claims Operations, Configuration, Compliance, Legal, Payment Integrity, Product, and other stakeholders to assess regulatory and contractual impacts, coordinate claims policy changes, establish appropriate controls, and support consistent policy implementation.

Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

Applicants for this job have the flexibility to work remote from home anywhere in the United States.

• Lead the development, review, approval, implementation, and maintenance of enterprise claims policies, procedures, and operational documentation.
• Establish policy frameworks, documentation standards, version controls, approval workflows, and governance practices that support consistent claim adjudication across products, platforms, and markets.
• Ensure claims policies align with federal and state regulations, CMS guidance, Medicaid and Medicare requirements, accreditation standards, provider contracts, and operational capabilities.
• Design and administer enterprise claims governance forums and decision-making processes for policy, process, adjudication logic, reimbursement methodology, and compliance-driven changes.
• Establish intake, prioritization, escalation, approval, and change management processes for regulatory updates and Payment Integrity initiatives affecting claims operations.
• Identify and implement opportunities to standardize claims operations across business units, vendors, health plans, and processing platforms.
• Assess policy and process changes to identify operational, compliance, and financial risks and ensure appropriate controls are maintained.
• Partner with Compliance, Legal, and audit teams to translate requirements into operational policies and support audits, corrective action plans, and regulatory examinations.
• Serve as a strategic liaison across Claims Operations, Technology, Product, Configuration, Provider Operations, Finance, Compliance, Legal, and health plan leadership to build stakeholder alignment.
• Provide executive-level recommendations and influence enterprise decisions related to claims strategy, policy governance, operational controls, and risk management.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: Bachelor's Degree in Business Administration, Healthcare Administration, Public Health, Finance, Nursing, Health Information Management, related field or equivalent experience required. 8+ years of progressive healthcare claims, payment operations, policy management, payment integrity, compliance, audit, or process governance experience required. 3+ years management experience required. Experience supporting government-sponsored programs including Medicaid and/or Medicare preferred. Experience leading cross-functional initiatives involving operations, compliance, legal, technology, and business stakeholders preferred. Demonstrated experience developing operational policies and governance structures in healthcare or managed care environments preferred.

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act