VP, Health Plan Operations
- Responsible for the development and administration of State Health Plan' s operational departments, programs and services, in alignment with Client' s overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulatory requirements.
- Under the leadership of the Plan President, this role 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
- This position 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 the Senior Plan leader and liaison for MHI 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 MHI shared services operations that support the Health Plan will have dotted line responsibility and accountability to this position.
- Proactively develops, tracks, and reports to Plan leadership MHI Service Operations performance relative to Plan compliance requirements, key performance targets and/or associated service level agreements.
- Quickly escalates performance issues to the Plan President and Plan leadership along with clear action plans to mitigate.
- This role requires the identification and adoption of best practices from across the enterprise for Health Plan and MHI Service Operations; developing strategies and tactics in partnership with MHI 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. In addition, 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.
- May directly manage the Health Plan main reception desk at Plans discretion.
- Other operational duties as assigned by the Plan President.
- Education Bachelor' s Degree in Business, Health Services Administration or related field, or comparable experience.
- Required Experience • 7-10 years' experience in Healthcare Administration, Health Plan Operations, Managed Care, and/or Provider Services.
- Experience managing/supervising employees.
- Demonstrated adaptability and flexibility to a rapidly moving business environment.
- Preferred Education Master' s Degree in Business, Health Administration or related field.
- Preferred Experience Experience with Medicaid and Medicare managed care plans.