AVP, Health Plan Operations

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

Essential Job Duties • Supports strategy development, vision and direction for designated state health plan operations function. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised. • Under the direction of senior leadership, directs and manages state health plan operations. • Demonstrates accountability for ensuring health plan operating metrics consistently meet and/or exceed all compliance requirements, key performance targets and associated service level agreements (SLAs). • Plans, organizes, staffs, and coordinates the operations of state Medicaid/Children's Health Insurance Program (CHIP), Medicare and Marketplace health plan operations. • 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; shared services operations that support the health plans have dotted line responsibility and accountability. • Proactively develops, tracks, and reports to plan leadership and enterprise operations, performance relative to plan compliance requirements, key performance targets and/or associated SLAs. • 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 full and consistent compliance with health plan state contracts and regulatory requirements; works collaboratively 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 the functionality of health plan operations. • Directly manages the plan's benefit configuration, claims payment policies and the maintenance or modification of such, to support accurate and timely claims payment. Also 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 the 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.

Required Qualifications • At least 10 years of health care operations, health care administration, and/or provider services experience, or equivalent combination of relevant