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:

- Bachelors 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.