Vice President, Claims

Role Overview

• Lead the teams responsible for end-to-end processing of medical and pharmacy claims from receipt through payment, including appeals and escalations.
• Ensure compliance with all contractual agreements, plan documents, and applicable regulations.
• Use data to understand all aspects of the claims operation, efficiently match supply to demand throughout the claims process, and identify synergies between workflows to eliminate unnecessary, redundant or inefficient work.
• Create and maintain process flows and standard operating procedures to ensure reliable execution.
• Provide business requirements and cross-functional support to the teams building Gravie’s technology applications.
• Support the creation of new and innovative health benefit plans, including developing innovative and efficient methods for delivery of Gravie’s promise of health benefits that everyone can love.
• Create processes for identifying process, system, and policy gaps affecting the timeliness, quality, and/or efficiency of our claims process; diagnosing root causes and other contributing factors; and architecting effective, sustainable solutions.
• Partner with the leadership of our Gravie Care member service operation to ensure escalation workflows are designed and operated effectively and our knowledge bases and training materials are timely, accurate and easy to digest.
• Possess a deep knowledge of regulations and compliance requirements related to self
• and level funded health plans and other components of employer health benefits offerings, including HRAs, HSAs, FSAs, dental, vision, and wellness benefits.
• Develop and communicate performance metrics and business updates internally and across the Gravie organization.
• Develop people to be the best they can be, motivate, empower, and encourage innovation from all employees.
• Build and maintain a comprehensive model of claims operations tasks and translate this model into effective cost of service modeling and metrics to drive budgeting, cost reduction decisions and business cases for investment.
• Demonstrate commitment to our core competencies of being authentic, curious, empathetic, creative and outcome oriented.

Requirements

• 15+ years of experience in health plan operations at a TPA or carrier with a deep understanding of self and level funded plans, including experience designing and reengineering operational processes.
• Ability to lead, support and develop front-line supervisors and managers and dive in and directly contribute key initiatives.
• Deep subject matter expertise in medical claims.
• Previously demonstrated success in project planning and execution.
• Working knowledge of network and provider contracts.
• Excellent communication skills.
• Demonstrated success getting results through collaboration.

Benefits

• alternative medicine coverage
• generous PTO
• up to 16 weeks paid parental leave
• paid holidays
• 401k program
• transportation perks
• education reimbursement
• paid paw-ternity leave