AVP Payment Configuration

Description and Requirements

The Assistant Vice President (AVP) of Provider Payment partners with senior leadership to design and implement the methods and procedures essential for successful claim & benefit configuration, provider onboarding, and maintenance of provider records. The incumbent provides strategic leadership and oversight to establish strategic plans and objectives that enable accurate, timely, and quality claims and provider payment practices. The incumbent ensures business outcomes are consistent with Healthfirst's values, policies, and procedures as well as compliance with relevant federal and state laws/regulations.

This position requires three days per week in office (Tues/Wed/Thurs) at 100 Church Street, NYC

• Implement and maintain the configuration of reimbursement rates and pricing methodologies needed to support contract terms with providers including contracted and out of network providers
• Ensure configurations accurately match fee schedules and negotiated rates match contracts so that claims are priced accurately
• Implement configuration of benefits to meet the needs of Product, Clinical, Medical Cost Management, and Regulatory requirements
• Ensure the quality of the configuration to meet outcomes aligned with the stakeholder requirements
• Ensure intake of provider contract related requests including gathering of all contract terms, contract creation, provider demographics & documentation required to validate a provider's eligibility and credentials for the purpose of providing care to our members
• Ensure proper set-up and maintenance of our Provider Database across Healthfirst systems including but not limited to new provider loading as well as changes and/or terminations of existing provider records thereafter
• Ensure appropriate systems testing, procedure/control development, and ongoing improvement
• Ensure all NY state and federal compliance, audit and regulatory requirements are met
• Oversee credentialing workflow and policies to ensure they are compliant and support timely loading of provider records
• Evaluate, develop, and recommend strategic plans to ensure modern and efficient Provider Payment experience
• Build, manage, develop, and continuously improve the Provider Payment experience to meet the diverse and dynamic needs of a growing, evolving organization
• Develop an effective team through hiring, training, coaching, and providing ongoing and constructive feedback
• Additional duties as assigned

• Bachelor's Degree from an accredited institution or equivalent work experience
• HS Diploma or GED from accredited institution
• Experience managing others in positions of increasing responsibility environment
• Prior experience within Health Insurance Operations
• Experience setting departmental strategy, communicating, and influencing impact and progress to senior leadership
• Experience with Medicare/Medicaid and Commercial Healthcare
• Experience thinking strategically and critically in developing solutions to complex problems
• Experience communicating to cross-functional groups within an organization

• Experience in the operations and management of large-scale operational team(s)
• Prior experience within technical knowledge in one or more of the Provider operational areas: Claims Configuration, Onboarding and Credentialing
• Excellent communication skills (verbal/written)
• Change leadership skills coupled with exceptional relationship building and influencing ability
• Ability to problem solve and approach issues strategically