Vice President, Healthcare Payer Domain
5 days ago
Job Description: Senior Vice President / Vice President, Healthcare Payer Domain
Position Summary:
The Senior Vice President (SVP) or Vice President (VP) for the Healthcare Payer domain will lead the strategic vision, operations, and innovation for the organization's payer-related services. This executive will be responsible for driving initiatives that improve payer processes, enhance member and provider experiences, and optimize cost and efficiency. The SVP/VP will work closely with executive leadership and healthcare partners to ensure the organization remains competitive and compliant in a rapidly evolving industry.
Key Responsibilities:
1. Strategic Leadership:
- Develop and execute a comprehensive strategy for the payer domain, focusing on member engagement, claims processing, provider relationships, and cost containment.
- Identify opportunities for innovation and implement solutions leveraging data analytics, AI, and automation to improve payer operations.
- Stay informed about industry trends, regulatory changes (e.g., CMS, ACA), and market dynamics to adapt strategies accordingly.
2. Operational Excellence:
- Oversee end-to-end payer operations and customer service.
- Ensure efficient and accurate processing of claims and reimbursement in compliance with industry standards.
- Drive initiatives to reduce administrative costs and improve overall operational efficiency.
3. Technology & Data Integration:
- Collaborate with technology teams to implement advanced platforms for claims adjudication, payment integrity, and member engagement.
- Leverage data analytics and predictive modeling to enhance risk management, improve care outcomes, and optimize value-based payment models.
- Ensure interoperability and compliance with healthcare standards such as EDI, HIPAA, and FHIR.
4. Leadership & Team Building:
- Build and lead high-performing teams across payer operations, technology, and analytics functions.
- Foster a culture of collaboration, accountability, and continuous improvement.
- Provide mentorship and leadership development opportunities for team members.
5. Stakeholder Management:
- Partner with providers, employers, brokers, and regulatory agencies to strengthen relationships and improve service delivery.
- Collaborate with clinical teams to align payer strategies with population health management and care delivery goals.
- Represent the organization at industry forums, conferences, and regulatory meetings.
6. Financial Management:
- Develop and oversee budgets for payer operations, ensuring cost-effectiveness and ROI.
- Identify opportunities to enhance revenue streams and reduce medical loss ratios (MLR).
Qualifications:
- Bachelor’s degree in Healthcare Administration, Business Management, or a related field; advanced degree (MBA, MHA) strongly preferred.
- 25+ years of experience in leadership roles within the healthcare payer sector.
- Proven expertise in claims management, value-based payment models, risk adjustment, and member engagement.
- Strong knowledge of payer-specific regulations, including CMS, HIPAA, and ACA.
- Experience with technology solutions for payer operations, including claims adjudication systems, analytics platforms, and CRM tools.
- Exceptional strategic thinking, decision-making, and problem-solving skills.
- Outstanding communication and interpersonal abilities, with experience working with executive leadership and external partners.
Key Competencies:
- Visionary leadership with a strong focus on payer transformation and innovation.
- Deep understanding of healthcare payer operations and regulatory environments.
- Skilled in financial management, including reducing administrative costs and improving MLR.
- Ability to lead large-scale projects and manage cross-functional teams.
This role is designed for a dynamic leader who can drive transformation in the payer space while maintaining a strong focus on regulatory compliance, operational excellence, and member satisfaction.
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