Fraud Claims Operations Representative Jobs (NOW HIRING)

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.  

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.  

The Director, Claims Operations oversees end-to-end claims functions, including claims processing, payment recovery, claim analysis and issue resolution, and provider appeals.  A skilled people and operations leader, the Director, Claims Operations ensures high-quality, timely, and accurate service delivery for customers, members, and providers across all lines of business in a dynamic, growth-oriented environment.  The role holds accountability for operational performance, cost management, and quality outcomes, while driving scalability and standardization to support geographic expansion and increasing complexity.

Key Accountabilities 

• Claims Operations Oversight
• Design, implement, and continuously enhance controls and reporting across Claims Operations
• Own MBRs and executive-level reporting, including ad hoc SLT requests
• Provide end-to-end oversight of claims processing from intake through adjudication and payment
• Own performance management across daily, monthly, and quarterly KPIs, ensuring controls and actions drive service, cost, productivity, and quality outcomes
• Partner cross-functionally (Payment Integrity, Customer Service, EDI, Configuration, Finance, IT, Compliance/SIU, Markets) to ensure accurate, timely claims outcomes and alignment across a matrixed environment
• Build and lead a high-performing organization, driving accountability, talent development, and engagement
• Drive operational excellence through issue resolution, root cause analysis, and continuous improvement across processes, policies, and technology to prevent recurrence and optimize end-to-end performance

• Strategic Planning
• Continuously assess and optimize people, process, and technology to exceed key performance measures (e.g., accuracy, quality, timeliness)
• Identify and prioritize improvement opportunities with clearly defined success metrics
• Develop business cases for large-scale initiatives and oversee execution against budget, timelines, and interdependencies
• Represent Claims Operations in governance forums and enterprise committees

• Improvement and Implementation
• Lead implementation of strategic initiatives across people, process, and technology
• Execute changes supporting process improvements, new business integration, and measurable performance outcomes
• Define and execute an optimized workforce strategy, including BPO partnerships, to drive cost efficiency and scalability

Required Qualifications 

• Bachelor's degree or equivalent experience in related field
• 10+ years of work experience beyond degree in healthcare, health plans and/or claims operations
• 5+ years of people leadership experience
• Experience partnering cross-functionally (e.g., Payment Integrity, Finance, IT, Compliance) to deliver end-to-end claims outcomes
• Strong track record of driving operational performance across service, cost, productivity, and quality metrics
• Strong analytical and problem-solving capabilities with a focus on root cause analysis and continuous improvement

Preferred Qualifications

• Experience with claims platform system migration in a build environment
• Proved expertise in change management with the ability to lead through change
• Ability to manage people and process in a highly matrixed and complex organization

an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, or Madison, WI.

The full salary grade for this position is $113,400 - $194,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $113,400 - $170,100. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.  

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law. 

Internal Applicants: We’re excited about your interest in growing your career at Medica! To be eligible to apply for internal opportunities, employees must have been in their current role for at least one year.  

Recruiter: Stacey Manley

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. 

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.