Providence Health & Services Executive Director, Health Plan Claims Service Operations in Beaverton, Oregon
The Executive Director, Service Operations Claims directs and oversees the operations of the claims department to meet operation, financial, and service requirements. Responsible for strategic processing and payment of claims. Keeps abreast of any changes to legislation and regulations that pertain to claims. Provide operational leadership, management and direction for all claims operational teams, limited to claims adjudication, referrals, claims compliance, new product implementation, claims support, and oversee the claim editing system, analysis, review of system configuration, encounter data, and coordinating external claims audits. It may also include responsibility for managing a key vendor/partner relationship. including negotiations and contracting. Product lines include Medicare, Medicaid, commercial group, commercial ASO, and individual plans. Primary membership base is in California, Oregon, Washington, and Montana. PHP also has large ASO clients in Washington and Alaska. Holds primary accountability for overall performance of the above functions for a growing client base over 640,000 members and pay claims across our network which includes 10 Providence acute care hospitals, in a manner consistent with the strategic direction of Providence Health & Services. The claims director is well versed and knowledgeable regarding all operational areas that impact the claims adjudication. They work in partnership with the Systems Administration department.
The primary challenge facing the Executive Director, Operations revolves around effective operations of assigned teams to insure performance meets PHP strategic initiatives, group retention, member loyalty and fiscal stewardship. This includes the correct and timely adjudication and payment of more than $2 billion in claims. There is a constant need for increased efficiency and automation, which presents a challenge in the light of increasing complexity of products, plans and regulations. This includes developing policies, practices, procedures and processes as well as keeping abreast of industry trends and innovations.
This position is the primary contact between PHP's Operations and IS departments. Information and data are the core of operations and as such, effective and efficient IS interfaces are critical. Also, as administrative costs become a critical factor in Health Plan's Commercial success, the link with IS for technology assistance is vital as a method of reducing and managing costs.
The health plan world becomes more complex each year, and it is necessary constantly to monitor organization structure, tools, training, employee satisfaction and workplace culture. Significant flexibility is required in this position, as assignments and priorities may change with little notice.
Incumbent must envision and project the future consistent with Providence Health & Services for the Health Plans in planning strategies, integration, growth, and continued success in the commercial and government market.
Incumbent must provide leadership for success of the Health Plans Operations while continuously scanning the landscape for best practices that would further enhance efficiency and service.
The incumbent will be responsible, as a member of a director team, for the activities that lead to accurate and timely claim processing to pay more than $2B claims. Must be able to partner effectively with peer Operations directors and managers to form a cohesive and cross-functional team, while modeling collaborative and positive leadership behaviors.
Responsible for the overall service quality and effectiveness of services provided throughout Health Plans operations. Assures the proper management, utilization, and enhancement of all resources, tangible and intangible. Supports FIBO initiatives of the Health Plan.
Provide strategic leadership to assigned operating units in a way that optimize quality, cost effectiveness, competitive edge, and responsiveness.
Serve as a liaison between PHP Operations and PHP Information Services for all production, technology assessment & planning, vendor analysis, as well as development and project work. Participation on the Agile reviews and working with the departments business owner to support the automation and efficiencies in the department.
Develop standards, policies, and performance objectives for assigned Operations departments.
Strive towards excellence in the attraction and development of Health Plan Operations professionals. Select and develops leaders who will meet the qualitative, quantitative, and mission related goals of this area of responsibility. Provide leadership, encouragement, and support to all Health Plan personnel by maintaining high standards of performance and delivery of service.
Responsible for preparing and maintaining assigned portion of Operations strategic plan, including the annual budget; has major responsibility for optimizing productivity and cost effectiveness throughout the operations and for identifying and monitoring key success measures.
Develop and monitor Operations organizational structure, including the delegation of duties and organizational development of key staff. Foster team work and creates a culture of employee empowerment.
Monitor staff training and performance for assigned departments, including new employee training as well as a comprehensive program designed to cross train employees in all functional areas.
Maintain knowledge of the market throughout the Northwest and the Providence Health & Services Regions.
Provide the vision and leadership necessary to establish future directions, develop appropriate strategies, and direct their implementation for the operations of the health plans.
Establish positive working relationships with physicians, vendors and other business entities throughout Providence Health & Services.
Represent PHP Operations and services to clients, potential clients, consultants and other community constituents in an appropriate manner as opportunities arise.
Keep abreast of, and recommends to senior management, the latest technology improvements in claims processing, customer service, eligibility and billing, configuration, electronic linkages, and core operational procedures.
Responsible for identifying key capital needs for PHP Operations.
In conjunction with Information Services & Planning, evaluate and prioritize key work projects and monitors progress while managing the utilization of scarce resources.
Assist in major product implementations.
Direct and respond to marketing RFP's regarding claims processing.
Support external audits.
Bachelor's Degree in Healthcare Administration, Business Administration or other related field.
Master's Degree in Healthcare Administration, Business Administration or other related field is preferred.
10 or more years of experience in health plan operations.
5 years in a senior Management role (Director level).
A track record showing the ability to effectively communicate organizational planning as well as effectively develop and meet budget requirements.
A deep understanding of all Health Plan Functions and successful application of project management skills, performance management skills and techniques, and demonstrated use of continuous quality and efficiency improvement tools.
A deep demonstrated understanding of all Health Plan offered products and services.
Demonstrated strong interpersonal skills internally within area of direct responsibility as well as all other areas within Service Operations, PHP, and PSJH as a whole.
Demonstration of strong team building skills and shown persuasive communication abilities.
Must be able to demonstrate the ability to work within team settings to enhance shared leadership philosophies, and to inspire and motivate managers to create and lead strong teams.
Must demonstrate innovative improvements to existing processes to create efficiencies.
Must be able to show an understanding of the importance and impact of quality initiatives to PHP - such as NCQA, HEDIS, and Medicare Five Star - and demonstrate support and improvement where needed.
Must have an understanding of phone and workflow related technologies with proven ability to make needed changes to improve quality and efficiency.
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Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Leadership
Req ID: 289802