Job Details

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The VP of Claims, Encounters and Payment Integrity Operations is a key member of the Executive Management Group reporting to the Senior Vice President of Health Plan Operations. This position is responsible for key functions of operations, including claims processing, encounters processes, payment integrity, compliance with state and federal regulations, operations training, performance measurement, project prioritization and operational capacity planning, among other duties.

Essential Responsibilities:

• Create and implement strategic and annual plans for claims, encounter processes, and payment integrity.
• Provide strategic leadership for line of business across the organization.
• Ensure consistent achievement of government contractual Service Level Agreements and Commercial Performance Guarantees while maximizing productivity and mitigating loss/deficiencies.
• Monitor and analyze operational trends to anticipate processing needs, ensuring proactive adjustments that align with performance expectations and service standards.
• Lead the design of scalable processes for claims adjudication and encounters submission.
• Explore and implement new opportunities and innovations to reduce claims errors and improve efficiency in the claims processing life cycle.
• Effectively lead claims cost containment team.
• Deliver business requirements and collaborate in developing and enhancing processing platforms for efficient and accurate claims adjudication.
• Champion cross-functional processes to ensure business readiness and operational excellence.
• Drive accountability within the claims organization by hiring, developing, and motivating talent to achieve success. Effectively manage claims vendors to ensure optimal return on investment.
• Develop strategic business partnerships with internal departments and leaders to ensure strong operating performance, high levels of member satisfaction and quality performance, access, compliance and audit readiness, and sound financial performance. Develop and monitor departmental budgets.
• Oversee Medicare Advantage and Medicaid operations to ensure regulatory compliance and effective internal controls.
• Ensure that all CMS guidelines, processes, and timelines are incorporated into day-to-day operations, in coordination with the Senior Vice President of Health Plan Operations, Compliance Officer, and Manager of Government Member Services, Enrollment, and Billing.
• Oversee the drafting and documentation of internal controls and reporting, Medicare Advantage and Medicaid policies and procedures, keeping all up to date and actionable.
• In collaboration with the plan Medical Director, identifies and monitors opportunities for improving health care costs. Working with Medicare Product and Sales identifies opportunities to increase membership and revenue.
• Responsible for hiring, staff development, coaching, performance reviews, corrective action and termination of employees.
• Assist in leading the enterprise organization as a member of the Executive Management Group.
• Actively participate as a key member in leadership and management meetings, as well as in strategic internal and external committees, to disseminate information across the organization and represent the company's philosophy.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of ten (10) years of experience in healthcare operations with an emphasis on design/re-engineering operations required. A minimum of five (5) years of experience in healthcare operations leadership required. Experience in process/workflow building and operational improvement required. Experience in creating a payment integrity program required.

Education, Certificates, Licenses: Bachelor's degree in business, finance, management, or related field required.

Knowledge: Demonstrated experience and success in working collaboratively in defining and achieving common goals, including the ability to create a vision that will inspire others. Ability to communicate, persuade, convince, influence, and negotiate with all levels including staff, management, boards of directors, employees and community stakeholders. Experience working with commercial and government programs including Medicaid, Medicare and DSNP programs. Able to find synergies between workflows and processes and work to eliminate redundancies. Deep knowledge of claims processes and processing systems. Process Improvement mindset. Experience in Change Management principles and the ability to identify interdependencies across people, process and technology.

Competencies

Authenticity

Building Organizational Talent

Coaching and Developing Others

Cultivating Networks

Customer Focus

Empowerment/Delegation

Emotional Intelligence

Establishing Strategic Direction

Leading Change

Optimizing Diversity

Passion for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 20% of the time.

Skills:

Accountable leadership, Business & financial acumen, Developing Networks, Driving initiatives, Empowerment, Influential Communications, Inspirational Leadership

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

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