Vice President, Claims and Provider Operations

Vice President, Claims and Provider Operations

The Vice President, Claims and Provider Operations leads the delivery of provider data management, original claims processing, and claims rework functions. They ensure 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.

Responsibilities :

• 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.

Minimum Qualifications :

Preferred Qualifications :

We are an equal opportunity employer. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and / or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.