Head of Health Plan Claims Operations

Head of Health Plan Claims OperationsAbout the CompanyFast-growing healthcare organization providing high-quality services at affordable pricesIndustryHospital & Health CareTypePrivately HeldAbout the RoleThe Company is in search of a Head of Health Plan Operations, Claims to spearhead the administration of claims for its growing health plan portfolio. The successful candidate will be responsible for the overall management of medical claims processing, ensuring accuracy, regulatory compliance, and operational efficiency. This leadership role involves overseeing both in-house and outsourced claims operations, leading performance improvement initiatives, and resolving complex claim issues. The Head of Health Plan Operations, Claims will also be tasked with collaborating across various functions to enhance the claims experience and will be the final escalation point for any challenging claim grievances, appeals, or provider disputes. Applicants must have a Bachelor's degree in a relevant field, with a Master's degree preferred, and at least 7 years' of experience in health insurance claims operations, including a minimum of 3 years in a leadership role within a managed care or health plan environment. The role requires a deep understanding of ACA, NSA, and state claims regulations, as well as experience with claims system implementations or conversions. The ideal candidate will possess advanced technical expertise in claims adjudication, coding standards, and workflow management, with a strong focus on regulatory compliance. Leadership skills, including the ability to manage change and make strategic decisions, are essential, as is a commitment to member and provider-focused, accurate, and fair claims processing.Hiring Manager TitleChief Operating OfficerTravel PercentLess than 10%FunctionsOperations