The posting
Job Description
The Sr. Director, Business Rule Modernization owns the capability enablement streams supporting the end-to-end health of the business rules governing claims adjudication across all lines of business. This role leads a structured Assess, Improve, and Monitor methodology to continuously evaluate how rules perform today, prioritize and execute modernization of the highest-impact rules, and sustain accuracy and control once improvements are in place. The Sr. Director directs a team of Senior Consultants accountable for building a centralized business rules registry, rationalizing logic that is currently fragmented across platforms, and identifying low-code and AI-enabled opportunities that reduce manual configuration and reconciliation. This role is central to modernizing adjudication rules for an AI-enabled future and requires close, ongoing collaboration with Claims Operations, Payment Integrity, Policy and Contract Management, and Information Technology to ensure business rules remain accurate, auditable, and positioned to scale with GuideWell's broader Core Admin Platform transformation.
Key Responsibilities
- Sets direction for business rule modernization goals that are aligned to the Core Admin Platform transformation, executive priorities, and adjudication accuracy success criteria.
- Leads a continuous assessment of business rules governing adjudication across all lines of business, including centralizing a single rules registry and inventory across the five platforms where rule logic is currently fragmented.
- Working with IT partners, solution the ability to audit current rule configurations for accuracy, redundancy, and conflict, and documents clear business ownership for each rule.
- Partners with Claims Operations, Payment Integrity, and IT to prioritize rule gaps by risk, cost, member and provider impact.
- Directs the design and implementation of modernized rule configurations, leading rules rationalization initiatives that consolidate fragmented logic into a single, governed source.
- Identifies and implements low-code and AI-enabled opportunities to automate rule configuration and maintenance, reducing manual reconciliation and operational burden.
- Develops and attains shared goals with functional business units and IT to create partnerships and joint accountability for rule modernization outcomes.
- Establishes ongoing governance and controllership that sustain rule accuracy and performance once improvements are implemented.
- Measures and reports on the efficiency and accuracy of systems and processes used to manage adjudication rules, flagging drift or emerging risk for correction.
- Ensures monitoring capabilities deliver a high degree of accuracy and auditability consistent with corporate policy, regulatory standards, and accrediting body criteria.
- Understands the industry and its dynamics as they pertain to adjudication and business rule modernization, serving as a liaison between senior business leaders and the enabling technical team so that business vision and priorities are understood and programs are effectively implemented, including alignment with the enterprise AI Coalition strategy.
Qualifications
- 10+ years related work experience including direct experience with claims adjudication, business rules configuration, or rules engine management.
- Proficient subject matter knowledge of business rules governing claims adjudication, including rule configuration, rules engines, and downstream code management.
- Demonstrated ability to apply a structured methodology, such as Assess, Improve, and Monitor, to evaluate and modernize complex rule sets.
- Demonstrated experience identifying and implementing low-code and AI-enabled automation to reduce manual configuration and reconciliation.
- Strategic thinking and planning abilities, with proven organizational skills and the ability to be flexible and work with ambiguity.
- Excellent written and verbal communication skills that scale to all levels of the organization.
- High critical thinking skills to evaluate alternatives and present solutions consistent with business objectives and strategy.
- Demonstrated experience with the concepts, theories, and processes of project management.
- Demonstrated ability to manage people, financial resources, and information.
- Strong demonstrated ability to establish, implement, and manage effective work processes and organizational structure.
- Must have strong demonstrated ability to provide input to, and influence, business plans and strategies.
- Knowledge of the system development life cycle.
Preferred Qualifications
- Experience in managing large-scale enterprise projects.
- Leadership experience in business operations.
- Experience with Diamond or similar core administration and claims adjudication platforms.
- Experience applying agentic AI or AI-enabled automation within claims or business rules operations.
Required Management Experience
- 5+ years direct supervisory/management experience
Required Education
- Bachelor’s degree or additional related equivalent work experience
General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Physical/Environmental Activities Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally
What We Offer: As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan including employer match;
- Paid time off, volunteer time off, 10 holidays and 2 well-being days;
- Additional voluntary benefits available; and
- A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $152,000 - $247,000
Typical Annualized Hiring Range: $152,000 - $190,000
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.
