Senior Vice President-Claims and Enrollment (Primarily Remote, North Carolina Based)

The Senior Vice President of Healthcare Claims Management is a key leadership role responsible for overseeing all aspects of claims processing operations, encounter submission and health plan enrollment. This is a strategic position that drives process improvement initiatives, ensures compliance with contract requirements and industry standards, fosters a positive culture, and impacts the organization’s success in delivering high-quality healthcare services to our members.

The successful candidate hired for the position, will be required to work onsite at the Alliance Home office (Morrisville, North Carolina), at minimum one day a week, as approved by their supervisor. 

Responsibilities & Duties

Strategic Leadership and Planning

• Develop and implement strategic plans for optimizing operations within the Department
• Align department activities with organizational goals and priorities
• Manage the Department budget and develop strategic plans for ongoing quality improvement

 Team Management

• Work with PODS to maintain and retain a highly qualified and well-trained workforce  
• Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes
• Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements
• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust  
• Ensure all staff are treated with respect and dignity
• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members
• Work to resolve conflicts and disputes, ensuring that all participants are given a voice
• Set goals for performance and deadlines in line with departmental and organization goals and vision
• Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development
• Cultivate and encourage efforts to expand cross-team collaboration and partnership
• Foster a culture of continuous improvement, accountability and collaboration

Department Operations

• Identify opportunities for process improvement and automation in the Department and in cross functional workflows
• Streamline workflows to enhanced efficiency and reduce errors
• Oversee the  development of processes and/or systems for claims and encounter related initiatives/programs, and/or regulatory changes/requirements
• Oversee the development of membership eligibility for state enrollment and ensure adherence to State guidance
• Direct monitoring of Medicaid eligibility requirements including any reports related to member updates as determined by staff
• Stay abreast on all regulatory and/or contractual changes, communicating changes to appropriate departmental staff and other departments
• Direct the development and maintenance of policies and procedures in relation to claims, encounters and enrollment in response to regulatory and business updates and communicate revisions to appropriate staff
• Collaboratively work with other departments to oversee Health Plan changes in ACS as it relates to service codes and benefit plans to ensure the accuracy of the system configuration and claims/encounter processing
• Oversee the development and monitoring of Key Performance Indicators for Claims Management

Systems Improvement and Innovation

• Oversee the development of new claims system for the purposes of future integration by monitoring the implementation of changes needed and continued meetings with internal staff
• Lead efforts related to identifying and implementing short and long range goals for enhancement of claims business development efforts with a continuous focus on optimization and quality control
• Partner with other departments, such as IT and Care Management, to define project parameters on claim adjudication improvements and regulatory report requirements

Analytics and Reporting

• Monitor analytics to ensure service, quality, and business goals are achieved
• Communicate and report effectively claims reports/ metrics and program updates to Executive Leadership and committees as required
• Communicate and report effectively to Leadership, staff, and providers as needed on changes to claim system and preparation for Tailored Plan
• Oversee CDW reporting to ensure compliance with state rules and timeframes, review and monitor results and provide quarterly updates to CFO

Internal and External