Associate Vice President of Health Plan Operations
$$$ Generous Relocation Package available to attract top-talent from around the Nation! $$$
VP of Health Plan Operations Job Summary:
VP of Health Plan Operations Background Profile:
- Directs and coordinates Health Plan Operations.
- Accountable for ensuring Health Plan Operating metrics consistently meet and/or exceed all compliance requirements as well as key performance targets and associated service level agreements
- Plans, organizes, staffs, and coordinates the operations of state Medicaid/CHIP, Medicare and Marketplace Health Plan operations.
- Works with staff and senior management to develop and implement improvements and oversight for non-clinical Health Plan operations.
- Serves as liaison for Service Operations, including: Claims, Configuration Information Management, Enrollment, Contact Center Operations, IT, Provider Configuration Management, Program Integrity, Risk Adjustment, Provider Resolution Team, Provider Appeal and Grievances, Member Appeals and Grievances, and other departments as required. These shared services operations that support the Health Plan will have dotted line responsibility and accountability to this position.
- Proactively develops, tracks, and reports Service Operations performance relative to compliance requirements, key performance targets and/or associated service level agreements. Quickly escalates performance issues to the Plan President and leadership along with clear action plans to mitigate.
- Responsible for the identification and adoption of best practices from across the enterprise for Health Plan and Service Operations; developing strategies and tactics in partnership with Service Operations to mitigate any issues or performance levels not meeting established service levels and provides corporate oversight including the efficacy of vendor management.
- Serves as liaison with Enrollment and Contact Center Operation leaders to ensure full and consistent compliance with Health Plan state contract and regulatory requirements. Works collaboratively with corporate business owners to mitigate risk related to enrollment processes and call center performance.
- Directs analytical activities to identify trends and potential opportunities with those Corporate Operations functions that may impact the functionality of Health Plan Operations.
- Directly manages the Plan's benefit configuration, claim payment policies and the maintenance or modification of such, to support accurate and timely claims payment.
- Manages the Plan's Provider Configuration/Information activities to ensure compliance with regulatory requirements and accurate claims and encounter submissions.
- Partners to support Plan encounter submissions to Regulators.
- Leads efforts through local Data/Business Analysts to audit provider contract loads and claims payments to ensure compliance with provider contract requirements.
- May directly manage the Project Management and Process Improvement teams and resources.
- Requires a Bachelor’s Degree in Business, Health Services Administration, Nursing, Healthcare or related field; Master’s Degree preferred.
- Around 7-10 years’ experience with Healthcare Administration, Health Plan Operations, Managed Care, and/or Provider Services at a Managed Care Organization.
- Requires at least 5-7 years previous health plan management experience, in roles of increasing responsibility.
- Significant Medicare, Medicaid, and Managed Care experience is required.
- Experience with strategic planning, implementing, and evaluating programs.
- Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
- Excellent verbal and written communication skills, as well as exceptional critical thinking skills.
- Possess very strong coaching/counseling skills including the ability to function as a mentor to management and employees.
- Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.