Vice President, Claims (Health Plan Administration)

TL;DR

Vice President, Claims (Health Plan Administration): Leading teams that design, operate, and optimize benefit configuration, claim adjudication, and provider payment functions with an accent on strategies to improve cost, quality, and efficiency of health plans. Focus on integrating new provider networks, enhancing payment integrity, and ensuring compliance with regulations for self- and level-funded plans.

Location: Remote

Salary: $214,125 – 314,050 annually

Company

Innovative health benefits provider for small and midsize businesses, founded by industry veterans with strong investor backing and high customer satisfaction.

What you will do

• Lead end-to-end processing of medical and pharmacy claims, including appeals and escalations.
• Develop strategies for cost, quality, and efficiency improvements, such as new provider networks and payment integrity.
• Use data to optimize workflows, match supply to demand, and eliminate inefficiencies.
• Create process flows, SOPs, and provide requirements for technology applications.
• Partner with member services for effective escalations and knowledge bases.
• Build cost models, metrics, and develop teams while driving innovation.

Requirements

• 15+ years in health plan operations at TPA or carrier, deep knowledge of self- and level-funded plans.
• Deep expertise in medical claims, process reengineering, and project execution.
• Lead and develop supervisors/managers, with working knowledge of network/provider contracts.
• Excellent communication and collaboration skills.

Nice to have

• Experience with Mphasis Javelina claims platform.
• Lean methodology qualification.

Culture & Benefits

• Non-hierarchical, merit-driven, high-performance environment with authentic, curious, empathetic culture.
• Generous PTO, up to 16 weeks paid parental leave, paid holidays, 401k, education reimbursement, transportation perks, alternative medicine coverage, paid paw-ternity leave.
• Annual bonus and stock options eligibility.
• Mission-driven work focused on equitable health insurance.