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Director, Medicare Claim Service Operations

Primary Location: Pittsburgh, Pennsylvania
Additional Locations: PA-Pittsburgh

The Director of Service Operations will oversee Medicare medical claim processing teams located within one of our core processing sites. The Director will manage up to 7 processing teams including front line Supervisors. Core responsibilities include the accurate and timely processing of medical claims on the HMO platform. The incumbent will participate in staffing and budget development as well as defining critical metrics for the Business. Continuous process improvement including the ability to perform root cause analysis, developing and implementing effective remediation plans is highly desired. Managing inventories across multiple works streams will be a primary component of the position.

Fundamental Components:

Oversees the operations of a service center handling Medicare medical claim processing and information flow across multiple work streams.

Directs implementation of service standards for the department to ensure delivery of quality-focused, consistent cost effective service and administration.

Analyzes operational practices for effectiveness and practicality, while creating a culture which is innovative in its approach to solutions.

Establishes a clear vision aligned with company values; sets specific challenging and achievable objectives and action plans; motivates others to balance customer needs, budgets, and business success.

Develops an organization that attracts, selects, and retains high caliber, diverse talent able to successfully achieve or exceed business goals; builds a cohesive team that works well together and across other business segment functions.

Effectively and proactively manages to budget, analyzing and acting upon financial variances from plan by identifying additional cost saving strategies.

Leads and builds high performance teams across units by providing leadership, mentoring and coaching in achieving understanding of the voice of the customer.

Accountable for leading staff in accordance with Aetna’s standards of leadership excellence.

Monitors and evaluates service center operational plans ensuring customer service standards are maintained during facility shutdowns (anticipated or unanticipated) and during business activity transfers between locations. Coordinates major plan modifications necessitated by unanticipated business or technology developments.

Develops and implements business strategies to provide accurate and proactive service to members, plan sponsors and brokers aligned to the service center. Provides operational support for market management of plan sponsors, members and networkproviders.

Ensures compliance outcomes are included in all plans and goals.

Background Experience:

5+ years’ experience in managing high volume transaction processing delivering on critical metrics that includes an emphasis on achieving financial outcomes.

Experience working and leading teams in a virtual environment.

Multiple years of proven leadership experience setting strategic direction and influencing change that resulted in quantifiable positive outcomes.

Proven strong leadership skills managing large high performance teams.

Healthcare experience preferred.

Experience working across boundaries including effective collaboration with business partners.

Medicare claim processing experience desired.

Bachelor's degree in a closely-related field, or equivalent combination of education and experience.

Additional Job Information:

Successful candidate will possess experience leading a large organization in a production environment. Effective collaboration and ability to lead and drive change is critical. Identifying opportunities for process improvement and experience developing effective remediation plans is highly desired. Project management experience is also desired.

Required Skills:
Leadership - Collaborating for Results, Leadership - Developing and Executing Strategy, Leadership - Engaging and Developing People

Desired Skills:
Leadership - Anticipating and Innovating, Leadership - Creating Accountability, Leadership - Driving a Culture of Compliance

Functional Skills:
Claim - Claim processing - Medical - Medicare, Claim - Management: > 25 employees

Technology Experience:
Aetna Application - HMO Claims Processing System

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)


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