Vice President Health Plan Operations

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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.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in business, Healthcare Admin, or related field;

EXPERIENCE:

1. Ten (10) years of progressive experience in the healthcare industry, with a focus on managing teams across Claims, Customer Service, Enrollment, Implementation, and Configuration

2. Commercial, Medicaid and Medicare Experience with P&L accountability

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Experience working in WV’s Managed Care Medicaid Program

2. Experience working on large (100k covered lives) core admin implementation projects

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Responsible for day-to-day operations of assigned business unit or product line ensuring product strategy developed and key priorities are implemented.

2. Execute projects and activities to ensure health plans are meeting all product goals.

3. Provide day-to-day oversight of assigned business units or product line.

4. 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.

5. Deep understanding of managed care models (HMO, PPO, Medicaid, Medicare Advantage, Duals, SNPs).

6. Familiarity with healthcare laws, reimbursement models, and value-based care initiatives.

7. Perform duties as senior liaison between product line, other business units, corporate, and external stakeholders related to operational areas.

8. Ensure compliance with CMS, NCQA, HIPAA, and other regulatory bodies.

9. Act as lead on new product implementations.

10. Oversee implementation and optimization of health plan operations systems (e.g., claims adjudication platforms, CRM tools).

11. Oversight of relevant corporate business units to ensure the development and implementation of operational work processes and systems within product lines to senior management.

12. Recruits, retains, and develops a high performing team

13. Participate in relevant boards, task forces, committees, meetings, and other activities.

14. Perform ongoing monitoring and tracking of department objectives and ensure adequate staffing to meet department needs for all regulatory standards.

15. Develops annual goals, prepares, monitors, and analyzes variances of departmental budgets to control and appropriately allocate resources.

16. Promote employee engagement and the professional development of staff members.

17. Performs other duties as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to stand and walk short distances for eight or more hours.

2. Frequent bending, stooping, or stretching.

3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

2. Some travel may be required for offsite meetings.

SKILLS AND ABILITIES:

1. Thorough understanding of product management programs and practices

2. Strong understanding of contemporary clinical, operational, and regulatory practices

3. Ability to work cooperatively as a team member with articulate oral and written communication and presentation skills.

4. Ability to work in a fast-paced and rapidly changing environment with attention to detail.

5. Ability to work proactively and independently to research and resolve complex issues.

6. Ability to apply relevant laws, regulations, requirements, and policy standards.

7. Experience in (or working knowledge of) formulary management

8. 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

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

649 SYSTEM Managed Care and Payer Relations

Address:

1085 Van Voorhis RdMorgantownWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.