Description

THE ROLE

The Vice President of Healthcare Operations, reporting to the Chief Enterprise IS and Operations Officer, will lead several operational functions that serve our members, providers, employers and partners. This position provides comprehensive operational strategic direction, management, continuous improvement, scale, oversight, and stability so that all operational functions are performing at their peak. This individual will manage several core operational functions including (but not limited to) configuration, enrollment, testing, member communications, ID cards, centralized training, command center, client implementation, and strategic planning & analysis teams.

Product lines include Medicare, Medicaid, commercial group, commercial ASO, and individual plans.

ESSENTIAL FUNCTIONS

Overall Management Responsibility:

• Lives out the highest levels of integrity every day and expects the same for the organization.

• Behaves in a manner consistent with PHP policies and promotes the mission and values of PHP.

• Leads with a social justice orientation in alignment with Providence Health Plan mission and values, fostering a sense of belonging and commitment to a diverse staff and organization.

• Leads a virtual / hybrid team of direct reports including Directors, Program Managers, and Analysts of approximately 100-250 individuals.

• Provides operational leadership for core Health Plan Operations functions.

• Designs and implements innovative operating models to support PHP’s overall growth strategy.

• Attracts, develops, and retains talent; fosters high-performing teams and culture of empowerment.

• Continuously scans the landscape for best practices to further enhance execution, efficiency, and effectiveness.

• Identifies key capital needs and develops and manages annual operating budget as appropriate.

• Adheres and upholds regulations and standards.

Claims:

• Oversee and coordinates all phases of health plan claims processing, from intake to adjudication, to ensure claims are processed accurately and promptly.

• Actively monitoring claims adjudication process, claims inventory and aging to ensure compliance with plan policies and procedures and state and federal regulations as applicable.

• Develop and execute strategies to enhance operational efficiencies, improve claims accuracy, reduce costs, and ensure adherence to regulatory requirements.

• Develop and manage the annual claims budget, ensuring claims processing costs are controlled and aligned with financial goals.

• Track key performance indicators (KPIs), including claim accuracy, turn-around time, and payment timeliness, and present regular performance reports to senior leadership.

• Ensure the claims department is adequately staffed with trained personnel to meet business goals and manage workload.

Enrollment & Billing:

• Lead, inspire, and develop a high-performing enrollment and billing team to support both new member enrollments and ongoing plan changes for existing members.

• Oversee all aspects of the enrollment process, including individual and group enrollments, open enrollment, special enrollment periods, and membership changes.

• Manage and continuously improve workflows to ensure efficient processing of member applications, verifications, and changes.

Configuration:

• Oversee the end-to-end configuration of health plan products, including plan designs, benefits, eligibility, and pricing structures.

• Works closely with other departments such as IS, product, claims, and member services to ensure the smooth integration of configurations across the health plan’s systems, driving operational efficiency, accuracy, and compliance.

• Continuously assess, improve, and optimize the configuration process to ensure speed, accuracy, and compliance in system set-up and maintenance.

Testing:

• Responsible for building a team to manage testing scripts for various operational scenarios

• Leads project testing strategy, design, and administration

• Manages testing automation tools and scripts

Plan Communications & ID cards:

• Oversee the team who delivers member communications related to configuration, enrollment, claims, and other related core operations.

• Oversee the creation and delivery of clear, timely, and accurate communications to health plan members.

• Accountable for filing of and on time delivery of all member materials.

• Responsible for ensuring timely and accurate processing of ID cards.

Command Center:

• Responsible for serving as the central point for monitoring and managing operations.

• Responsible for facilitating communication between different departments, teams, and stakeholders, ensuring that everyone is aligned and informed and mitigating performance issues.

• Responsible for supporting decision-makers in taking swift action to mitigate problems and improve operational efficiencies.

Client Implementations:

• Provides end-to-end project management oversight and coordination across functions for account / client implementations across all lines of business.

• Responsible for new setup implementation and renewals, holding accountability for setup & operations “check-out” prior to and 30 days after 1/1 go-live.

Training:

• Responsible for centralizing a team of trainers to who will be responsible for designing, delivering, and managing Operations training program.

• Develop customized training solutions for different departments, ensuring that specific needs (e.g., claims processing, member services, provider services) are addressed.

• Oversee the creation of learning materials such as manuals, online courses, job aids, and interactive eLearning modules.

• Implement blended learning approaches that combine in-person training, virtual learning, and self-paced online resources to maximize engagement and effectiveness.

Strategic Planning & Analysis:

• Responsible for the success of standing up a new organization to support operational reporting and analysis.

• Accountable for managing all data analytics requirements for the Healthcare Operations, Transformation, and Advocacy Services teams, including:

• Daily operational reporting for all areas of the business

• Report on key performance indicators (KPIs)

• Responsible for supplying data Monthly Business Review metrics across multiple departments

• Analyzes, diagnoses, and corrects operational and efficiency issues within the operational support model to improve team efficiencies.

• Build workforce management model to help the organization predict the demand for labor based on historical data, trends, seasonality and business changes.

• Monitor workforce performance in real-time and adjust as needed to ensure smooth operations.

QUALFICATIONS

• Bachelor's Degree in any relevant field; or equivalent education/experience

• Master's Degree in Business Administration, Healthcare Administration, Operations Management, or a related field; or equivalent education/experience

• 10 or more years of experience with operational planning, operations functions, management services, and operational excellence within a large health or social service agency, non-profit, or mission-driven corporation.

• Minimum of 10 years of experience acting in managerial / cross-functional roles at a health plan or other related roles. Prior experience managing entire business units / an expansive purview (i.e., hundreds of FTEs in total). Prior experience working directly with C-suite leadership and other senior leadership

• 10 or more years of experience leading large organizational change across multiple functional departments in a matrixed organization of the size and scale of Providence St. Joseph Health

• 10 or more years of demonstrated experience managing cross-functional teams/processes with track-record of improving operational efficiency.

• Experience working in or with an integrated health system; legal experience; financial accounting; change and transition management; professional consulting experience (preferred)

• Possesses the ability to lead and work within virtual/hybrid team settings, and confidently during times of significant change, transition, complexity, and ambiguity

• Is highly independent / self-directed and a strategic thinker with sound business judgment

• Has a passion for leading operational teams and solving complex problems

• Demonstrates a high level of creativity and problem-solving skills to identify innovative and appropriate approaches to business issues

• Is able to balance multiple competing priorities and exercise rapid business judgment to support effective real time decisions

• Possesses proven ability to inspire and motivate managers to build and grow high-performing teams, organizational and analytic skills

• Has a nuanced understanding of complexities of the healthcare industry, health plan dynamics / operations, and interconnectivity of each major industry player (e.g., health plans, hospitals, life sciences firms)

• Has knowledge of core health plan operational functions, including but not limited to: vendor management, compliance / regulatory management, configuration, enrollment, claims processing / adjudication

• Possesses proven ability to lead overall business performance, even during times of setback and obstacles

• Demonstrated ability to establish and achieve audacious goals

• Drives execution of all operations programs and processes, while meeting budget, quality, and efficiency requirements

• Maximizes opportunities and makes bold decisions at the right time

• Has ability to communicate Providence Health Plan’s vision, mission, key initiatives, updates, and priorities across all levels to support a culture of unity and transparency

• Possesses excellent interpersonal skills, communication and relationship building skills, and the ability to build a high-performance team and rapport and credibility with business leaders

• Demonstrated ability to influence and receive buy-in across level and audience.

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.

Requsition ID: 348681
Company: Not Applicable
Job Category: General Operations
Job Function: Operations
Job Schedule: Full time
Job Shift: Day
Career Track: Leadership
Department: 5018 OPS PHP CSO OR REGION
Address: OR Portland 4400 NE Halsey St
Work Location: Providence Office Park Portland Bldg 1-Portland
Workplace Type: Remote
Pay Range: $97.95 - $178.94
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.