AVP, Health Plan Operations

About the Role

Provides strategy and leadership to the team responsible for the development and administration of state health plan operational functions, programs, and services. Ensures functional operations, contractual compliance, and alignment with health plan member satisfaction, retention, quality, and financial goals.

Responsibilities

• Supports strategy development, vision, and direction for designated state health plan operations function.
• Demonstrates accountability for performance and financial results; keeps executive leadership apprised.
• Directs and manages state health plan operations under the direction of senior leadership.
• Ensures health plan operating metrics consistently meet or exceed all compliance requirements, key performance targets, and associated service level agreements (SLAs).
• Plans, organizes, staffs, and coordinates operations for state Medicaid/CHIP, Medicare, and Marketplace health plans.
• Collaborates with staff and senior leadership to develop and implement improvements and oversight for non-clinical health plan operations.
• Serves as leader and liaison for corporate operations, including: claims, configuration information management, enrollment, support center operations, information technology, provider configuration management, program integrity, risk adjustment, provider resolution, provider appeals and grievances, member appeals and grievances, and other departments as required.
• Proactively develops, tracks, and reports performance relative to plan compliance requirements, key performance targets, and SLAs to plan leadership and enterprise operations.
• Quickly escalates performance issues to senior leadership with clear action plans to mitigate.
• Identifies and adopts best practices across the enterprise for health plan implementation; develops strategies and tactics in partnership with enterprise operations to mitigate issues or performance levels not meeting established service levels, including efficacy of vendor management.
• Serves as liaison with enterprise enrollment and support center operations leaders to ensure compliance with health plan state contracts and regulatory requirements; collaborates with corporate business owners to mitigate risk related to enrollment processes and support center performance.
• Directs analytical activities to identify trends and potential opportunities with corporate operations functions that may impact health plan operations.
• Manages the plan’s benefit configuration, claims payment policies, and their maintenance or modification 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 with local data/business analysts to audit provider contract loads and claims payments to ensure compliance with provider contract requirements.
• May directly manage project management and process improvement teams and resources.
• Hires, trains, develops, and manages team; demonstrates accountability for team performance and achievement of quality/department-specific goals.
• Develops and sustains a high-performance team dedicated to best-in-class solutions; responsible for attracting, developing, and retaining top-tier talent to support strategy and long-term business objectives.

Requirements

• At least 10 years of health care operations, health care administration, and/or provider services experience, or equivalent combination of relevant education and experience.
• At least 5 years of management/leadership experience.
• Extensive experience with Medicare, Medicaid, and Marketplace plans.
• Experience with prompt pay laws.
• Extensive claims-related experience.
• Demonstrated adaptability and flexibility to change, and to new ideas and approaches.
• Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Ability to work cross-collaboratively across a highly matrixed organization and establish and maintain effective relationships with internal and external stakeholders.
• Project management experience.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office suite (including Excel) and applicable software programs.

Pay

Pay Range: $122,430.44 - $238,739.35 per year. Actual compensation may vary based on geographic location, work experience, education, and/or skill level.