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Vice President Health Plan Claims and Operations

Ontario, CA, USA | Prime Healthcare

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    General Management
  • Experience:
    7-10 years
Job Description:
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The Vice President of Health Plan Claims and Operations 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. Through in-depth audit and review of Claims data, the VP will identify financial savings across all aspects of the Employee Health Plans.

The VP of Health Plan Claims and Operations will provide strategic leadership and development of the Claims Department and its employees, as well as collaborate with Network Development, Provider Affiliation and Member Relations, Contracting, and Benefits Administration to ensure data integrity and to drive financial and operational value across Employee Health Plans to maximize benefit coverage while containing cost.

The VP of Health Plan Claims and Operations will partner with local C-Suites and Hospital Administration to execute goals and plans of the Employee Health Plans. Through inter-professional collaboration, The VP will ensure that TPA and Health Plan are notified in a timely fashion of any changes in process or procedures which would impact their functions.


Required qualifications:

Master’s Degree in Business Management, Healthcare Administration, or other relevant fields.

A minimum of seven (7) to ten (10) years prior work experience in Claims Operations and Health Plan Strategy, in a Managed Care, Self-Funded or hospital setting is required.

Analytical skills with emphasis on generation and utilization of data to drive operational and financial performance.

Ability to work in a complex, rapidly evolving environment with multiple internal and external entities and boundaries.

Strong interpersonal skills, problem solving and project/time management essential.

Ability to develop presentations to all levels using Microsoft Office applications.

Strong knowledge of medical coding (ICD-10, HCPCs/CPT, etc.)

Preferred qualifications:

Certified Professional Coding Certification, AIC, ARM, or equivalent.

Familiarity with multiple Business Intelligence software systems and daily usage of at least one.

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