Vice President Health Plan Operations

WVU Medicine

About The Position

The Vice President will lead core Operations departments at Peak. The VP of Operations will lead daily operations, strategy, and efficiency for a health plan, overseeing claims, member services, sales and enrollment, ensuring compliance (CMS, HIPAA), managing budgets, driving digital initiatives, and coordinating with clinical/admin teams to meet strategic goals, enhance member experience, and control costs. The Vice President, Health Plan Operations should be dedicated to delivering service and operational excellence through a focus on continuous improvement in the areas of contribution, competencies, and coordinated performance of the teams reporting into this role. This role will be tasked with overseeing the development and operational execution of all operational processes in line with regulatory standards while enhancing quality and effectiveness. Additionally, the role will need to utilize advanced technical knowledge to resolve complex issues. This involves setting objectives, determining approaches, allocating resources, schedules, and goals. A successful candidate for this role will need to possess strong leadership skills and have a commitment to delivering exceptional service to our members along with an in-depth knowledge of Commercial, Medicare, and Medicaid processes and regulatory requirements.

Requirements

Bachelor’s degree in business, Healthcare Admin, or related field
Ten (10) years of progressive experience in the healthcare industry, with a focus on managing teams across Claims, Customer Service, Enrollment, Implementation, and Configuration
Commercial, Medicaid and Medicare Experience with P&L accountability
Thorough understanding of product management programs and practices
Strong understanding of contemporary clinical, operational, and regulatory practices
Ability to work cooperatively as a team member with articulate oral and written communication and presentation skills.
Ability to work in a fast-paced and rapidly changing environment with attention to detail.
Ability to work proactively and independently to research and resolve complex issues.
Ability to apply relevant laws, regulations, requirements, and policy standards.
Experience in (or working knowledge of) formulary management
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging

Nice To Haves

Experience working in WV’s Managed Care Medicaid Program
Experience working on large (100k covered lives) core admin implementation projects

Responsibilities

Responsible for day-to-day operations of assigned business unit or product line ensuring product strategy developed and key priorities are implemented.
Execute projects and activities to ensure health plans are meeting all product goals.
Provide day-to-day oversight of assigned business units or product line.
Collaborate with multiple stakeholders and business unit leadership to establish strategic vision, operational objectives, and policies and procedures ensuring compliance with state and federal contracts, related laws, regulations and executive orders.
Deep understanding of managed care models (HMO, PPO, Medicaid, Medicare Advantage, Duals, SNPs).
Familiarity with healthcare laws, reimbursement models, and value-based care initiatives.
Perform duties as senior liaison between product line, other business units, corporate, and external stakeholders related to operational areas.
Ensure compliance with CMS, NCQA, HIPAA, and other regulatory bodies.
Act as lead on new product implementations.
Oversee implementation and optimization of health plan operations systems (e.g., claims adjudication platforms, CRM tools).
Oversight of relevant corporate business units to ensure the development and implementation of operational work processes and systems within product lines to senior management.
Recruits, retains, and develops a high performing team
Participate in relevant boards, task forces, committees, meetings, and other activities.
Perform ongoing monitoring and tracking of department objectives and ensure adequate staffing to meet department needs for all regulatory standards.
Develops annual goals, prepares, monitors, and analyzes variances of departmental budgets to control and appropriately allocate resources.
Promote employee engagement and the professional development of staff members.
Performs other duties as assigned.