Vice President of Health Plan Operations and Claims

Prime Healthcare Management Inc • Ontario, CA

103d • $150,000 - $250,000

About The Position

Prime Healthcare is actively seeking a Vice President of Health Plan Operations and Claims to join our corporate team in Ontario, California. This position is responsible for the development and execution of Claim Operations strategies, end-to-end Claim process automation, optimization and management, identifying and leveraging technology and data to improve the quality and minimize process cost of Claims for all Prime Healthcare’s self-insured Employee Health Plans. The VP will conduct in-depth audits and reviews of Claims data to identify financial savings across all aspects of the Employee Health Plans. Additionally, the VP will provide strategic leadership and development of the Claims Department and its employees, collaborating with various departments to ensure data integrity and drive financial and operational value across Employee Health Plans. The role requires partnering with local C-Suites and Hospital Administration to execute goals and plans of the Employee Health Plans, ensuring timely communication of any changes in processes or procedures that may impact functions.

Requirements

• Master’s Degree in Business Management, Healthcare Administration, or relevant fields.
• 7 to 10 years of experience in Claims Operations and Health Plan Strategy.
• Experience in Managed Care, Self-Funded, or hospital settings.
• Strong analytical skills with emphasis on data utilization.
• Ability to work in a complex, rapidly evolving environment.
• Strong interpersonal skills, problem solving, and project/time management.
• Ability to develop presentations using Microsoft Office applications.
• Strong knowledge of medical coding (ICD-10, HCPCs/CPT, etc.)

Nice To Haves

• Certified Professional Coding Certification, AIC, ARM, or equivalent.
• Familiarity with multiple Business Intelligence software systems.

Responsibilities

• Develop and execute Claim Operations strategies.
• Automate and optimize end-to-end Claim processes.
• Identify and leverage technology and data to improve Claims quality and reduce costs.
• Conduct audits and reviews of Claims data to identify financial savings.
• Provide strategic leadership and development of the Claims Department.
• Collaborate with Network Development, Provider Affiliation, Member Relations, Contracting, and Benefits Administration.
• Ensure data integrity and drive financial and operational value across Employee Health Plans.
• Partner with local C-Suites and Hospital Administration.
• Communicate changes in processes or procedures to TPA and Health Plan.

Benefits

• Paid time off
• 401K retirement plan
• Medical, dental, and vision coverage
• Tuition reimbursement
• Voluntary benefit options

What This Job Offers

• Job Type: Full-time
• Career Level: Executive
• Education Level: Master's degree
• Number of Employees: 5,001-10,000 employees