Head of Healthcare Claims and Operations
Head of Health Plan Operations, Claims
Location: New York City, NY (Hybrid)
Department: Operations
Reports To: Chief Operating Officer
About the Role
A fast‑growing, mission‑driven healthcare organization is seeking a Head of Health Plan Operations, Claims to lead claims administration for its expanding health plan portfolio. This organization is committed to making high‑quality, affordable healthcare accessible to all and is looking for a seasoned leader who thrives in dynamic environments, enjoys building operational excellence, and is passionate about improving member and provider outcomes.
Position Summary
The Head of Health Plan Operations, Claims oversees all aspects of medical claims processing, ensuring accuracy, regulatory compliance, and operational efficiency. This role will manage outsourced claims operations, lead performance improvement initiatives, resolve complex claim issues, and collaborate cross‑functionally to support a best‑in‑class claims experience. Expertise in health insurance, claims adjudication, and managed care operations is essential.
Key Responsibilities
Claims Operations Leadership
- Oversee outsourced claims processing teams to ensure compliance with federal/state regulations, accreditation standards, and internal KPIs.
- Monitor daily claims operations: adjudication, rework, provider disputes, backlog management, and workflow optimization.
- Serve as the final escalation point for complex claim grievances, appeals, and provider disputes.
- Conduct routine quality audits to maintain accuracy and reduce error rates.
- Analyze claims data to identify trends, elevate payment accuracy, strengthen cost‑containment efforts, and improve operational performance.
- Draft and maintain claims operations policies, procedures, and documentation.
- Develop reporting requirements, dashboards, and KPI frameworks for leadership visibility.
- Collaborate with utilization management, compliance, finance, provider operations, engineering, and member services to resolve operational issues and streamline processes.
System & Vendor Management
- Lead the selection and oversight of claims‑related vendors (clearinghouse, subrogation, COB, payment integrity, FWA, payment optimization).
- Act as operational lead for claims system changes, enhancements, and implementations.
- Define business requirements, test cases, and implementation timelines in collaboration with engineering and analytics teams.
- Lead User Acceptance Testing (UAT) and validation of configuration, pricing, and claims logic.
- Oversee training plans for outsourced claims teams and monitor ongoing performance.
Qualifications
- Bachelor's degree in healthcare administration, business, finance, or related field (master's preferred).
- 7+ years of experience in health insurance claims operations, with 3+ years leading claims teams in a managed care or health plan environment.
- Experience with claims system implementations or conversions.
- Strong understanding of ACA, NSA, and state claims regulations; familiarity with EDI transactions and claims platforms.
- Proven ability to build, lead, mentor, and develop high‑volume operational teams.
- Exceptional analytical, problem‑solving, and communication skills.
Skills & Competencies
Technical Expertise
- Advanced knowledge of claims adjudication, coding standards (ICD, CPT, HCPCS), and claims workflow management. QNXT software knowledge ideal.
- Strong regulatory compliance understanding across federal and state landscapes.
- Data analysis, KPI monitoring, and performance reporting.
Leadership & Strategy
- Effective team leadership, coaching, and performance management.
- Ability to manage organizational change, including system upgrades and operational redesigns.
- Strong decision‑making balancing compliance, cost, and customer experience.
- Skilled in conflict resolution, especially for escalated provider grievances.
Member & Provider Focus
- Commitment to accurate, timely, and fair claims processing.
- Experience supporting provider dispute resolution and payment integrity initiatives.
Work Environment
- Hybrid role requiring regular travel to the New York City office.
- Home workspace must support confidential, HIPAA‑compliant work.
- Occasional travel may be required.
FAQs
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