Location : Chennai/Hyderabad.
Key Responsibilities:
Strategic Leadership:
- Develop and implement a long-range plan for the payer domain-including member engagement, provider contracting, claims integrity, and value-based reimbursement.
- Drive innovation through data analytics, AI, automation, and predictive modeling.
- Monitor trends in CMS, ACA, FHIR, HIPAA, and EDI standards, adapting strategy proactively.
Technology & Product Leadership:
- Partner with product and engineering teams to deploy advanced claims adjudication systems, payment integrity platforms, and member/provider CRM portals.
- Integrate analytics and predictive risk models to optimize value-based payment programs.
- Ensure interoperability, FHIR compliance, and robust data privacy/security standards.
Operational Excellence:
- Oversee end-to-end payer technology delivery-claims adjudication workflows, payment post- processing, provider reimbursement models, and customer-facing systems.
- Drive cross- functional initiatives to reduce administrative costs and minimize claim denials and leakage.
Team Leadership & Talent Development:
- Build and mentor high-performing product, engineering, and project management teams.
- Cultivate a culture of collaboration, innovation, accountability, and continuous improvement.
Stakeholder Management:
- Engage key external stakeholders: payers, providers, brokers, employers, and regulatory bodies.
- Collaborate with clinical/population health leaders to align payer strategy with care delivery goals.
- Represent your organization in industry forums, trade associations, and legislative engagements.
Financial & Value Management:
- Drive financial strategy for payer services, optimizing ROI and reducing medical loss ratio (MLR).
- Oversee budgets, pricing models, and cost-reduction strategies tied to value-based contracting and digital automation.
Qualifications:
- Education: Bachelor's in Healthcare Administration, Business, or related field; MBA, MHA, or advanced degree strongly preferred.
- Experience: 25+ years of progressive leadership in healthcare payer domain, leading product or engineering-driven payer transformation.
- Domain Expertise: Deep knowledge of claims adjudication, provider contracting, reimbursement models (FFS / value- based), risk adjustment, and member engagement platforms.
- Technical Acumen: Hands-on experience with payer systems (analytics platforms, CRM, adjudication engines), interoperability standards (EDI, FHIR), and data security regulations (HIPAA).
- Leadership Fit: Track record of building and leading large teams, partnering across executive, clinical, finance, and technology functions.
- Communication & Influence: Exceptional presence with ability to engage Executive and Board-level stakeholders, negotiate complex payer contracts, and drive thought leadership.
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