The Vice President of Plan Operations will lead the team responsible for product and plan design, member engagement, member experience, and core administration.
KEY RESPONSIBILITIES:
- This role will be pivotal in managing the relationship with the third-party administrator (TPA) and ensuring efficient processes, compliance, and continuous improvement.
- The Vice President of Plan Operations will collaborate closely with the HR department to design benefits and ensure alignment with organizational goals.
- They will also work with the TPA to monitor operational performance and identify improvement opportunities.
- Additionally, they will partner with the finance team to manage the budget and financial performance of the health plan, the VP Pharmacy for performance on pharmaceutical spending targets, and the clinical team for population management.
STRATEGICE PLANNING AND PROCESS IMPROVEMENT:
- Develop and implement strategies for efficient operations, streamlining processes, and identifying areas for improvement.
- Develop and implement strategies to enhance member experience with a focus on engagement.
PLAN DESIGN,IPLEMENTATION, AND ENHANCEMENT OF PRODUCTS AND BENEFITS:
- Oversee the development and implementation of the benefit design, product offerings, implementation of services; and evaluate/optimize cost-sharing mechanisms.
- Partner with Emory HR to design benefits and be the first point-of-contact for Emory HR.
OVERSEE OPERATIONS:
- Work with HR and TPA to ensure high fidelity for enrollment, ID card distribution, accurate provider directories, performance on VBC contracts, benefit adjudication, appeals, and grievances.
- Collaborate with the TPA to understand operational performance, hold accountable to SLAs and PGs, and identify approaches to improve performance.
- In conjunction with VP, Pharmacy, ensure PBM operational performance is at high standard.
PROVIDER RELATION:
- Develop, manage, assess provider networks; manage relationships with providers, negotiate contracts (where necessary), and ensure quality of care.
CLAIMS MANAGEMENT:
- Oversee TPA claim processing, ensure accurate and timely payment of claims, and identify areas for cost reduction.
COMPLIANCE AND AUDITING:
- Maintain compliance with regulatory requirements, conduct internal audits, and manage corrective action plans.
FINANCIAL MANAGEMENT:
- In conjunction with Sr. Director, Finance, oversee financial performance, manage budget and costs, and identify opportunities for cost savings.
TECHNOLOGY AND DATA:
- Leverage technology and data to improve operations, enhance efficiency and beneficiary experience, and track performance.
TEAM LEADERSHIP AND DEVELOPMENT:
- Provide leadership, guidance, and development for the operational team.
COMMUNICATION AND COLLABORATION:
- Collaborate with other departments and entities (e.g., HR, compliance, legal, etc.) and external stakeholders (e.g., EHC, EU University Senate) to achieve organizational goals.
RISK MANAGEMENT:
- Understand and mitigate financial risks associated with self-funding such as large claims and fluctuations in healthcare costs.
ADVISORY AND GUIDANCE:
- Work with external employers and advisors to design and implement effective self-funded plans.
- Direct Reports
PRODUCT AND NETWORK DESIGN LEAD:
- Identifies and coordinates all product elements providing a cohesive vision (e.g., clinical programs, digital tools, ancillary benefits, network breadth, depth, and performance).
PLAN OPERATIONS MANAGEMENT LEAD:
- Oversee operational aspects of the health plan, ensuring efficient processes, compliance, and continuous improvement.
EXPERIENCE LEAD:
- Create and implement strategies to enhance member experience with a focus on engagement.
HEALTH AND WELLNESS SPECIALIST:
- Develop and implement health and wellness programs to boost member well-being and employee productivity, while aligning with health plan strategy.
NAVIGATION/MEMBER SUPPORT STAFF:
- Assist members in understanding and utilizing health plan benefits, provide guidance on plan options, coverage details, and resolve issues or concerns to ensure positive member experience.
MINIMUM QUALIFICATIONS:
- Bachelor's degree in Business Administration, Healthcare Management, or related field; MBA preferred.
- Ten years of experience in health plan operations, with at least 5 years in a leadership role.
- Strong understanding of health plan strategy and operations, product design, and benefit administration.
- Excellent communication, leadership, and organizational skills.