Vice President, Claims and Provider Operations

Description and Requirements

The Vice President, Claims and Provider Operations leads the delivery of provider data management, original claims processing, and claims rework functions. They ensures the successful operation and delivery of Healthfirst claims and provider payment services for federal, state, and commercial programs through standardization, optimization, and communication. The VP continuously works to increase our provider data capabilities, improve accuracy, and ensure compliance while advancing our unique sponsorship model by leading network expansion initiatives, increasing member access to care and overall customer engagement across all channels. He/she provides strategic oversight and leadership to claims-related root cause analysis and determinations and works cross functionally with key operational areas to cure systemic issues. He/she directs and ensures the efficient and compliant operational management of Claims with emphasis on execution, outcomes, continual improvement, and performance enhancement. This role is instrumental in ensuring overall adherence to regulatory expectations while improving the overall quality of work output. The role requires cross-functional work to ensure department and corporate strategies are executed and achieved enterprise-wide.

• Provides strategic guidance, direction, and management to lead and support a workforce in the areas of provider lifecycle management, including provider contracting, provider data management, directory data quality, credentialing, and other areas that impact the Healthfirst delivery system
• Evaluates, develops, and recommends strategic plans to ensure modern and efficient claims management and provider payment
• Analyzes, evaluates, develops, and leads implementation of strategic plans in alignment with the future vision of Claims ,Healthfirst delivery system and the company.
• Establishes and communicates current and long-range department goals and objectives and monitors results on an ongoing basis, adjusting plans and performance expectations to achieve targeted results.
• Develops, formulates, recommends, and implements decisions regarding policy, standards, methods, procedures, and functions.
• Ensures productivity meets or exceeds service and quality standards
• Develops provider outreach strategy and monitors results of provider Access & Availability and After-hours surveys to ensure delivery system compliance and improve member access to care.
• Identifies and implements training and education opportunities across the organization to improve delivery system and provider operations.
• Ensures all NY state and federal compliance, audit, and regulatory requirements are met.
• Builds, manages, develops, and continuously improves delivery system operations to meet the varied and dynamic needs of a growing, evolving organization.
• Develops an effective team through hiring, training, coaching, and providing ongoing and constructive feedback
• Develops and manages department budget, including monitoring expenditures and reporting results.
• Communicates operational results to executive leadership using standardized reports, dashboards, and frequent verbal updates through participation in management meetings and operational review processes.
• Keeps abreast of industry developments, particularly those which impact the delivery system
• Stays current with technology, processes and best practices and leverages knowledge to identify opportunities for training and process improvement
• Performs other duties as necessary or assigned

• Bachelor's Degree from accredited program or equivalent work experience
• Working experience facilitating business objectives within a highly regulated industry
• Experience leading teams, both managers and individual contributors, to identify opportunities, develop, and execute action plans
• Proven experience in root-cause resolution and managing cross-functional projects
• Proven ability to develop strong interpersonal relationships, as a leader and team member with experience communicating and influencing impact and progress to senior leadership level
• Successful track record developing creative, workable strategies and tactics to accomplish division, corporate and plan goals
• Experience managing budget and allocating resources with reputable record in the execution of complex projects and programs while managing operational and health care cost budgets

• Master's degree or MBA from an accredited institution
• Strong public speaking and oral and written communication skills, with experience communicating complex messages to executive-level audiences
• Ability to coordinate and motivate people to achieve results
• Ability to train, coach and develop staff to accomplish established goals
• Ability to implement corrective action plans and recommending approaches on how to improve efficiency in process flows