Job Description

Position Summary: This executive will be responsible for the Healthcare Payer domain will lead the strategic vision, operations, and innovation for the organization's payer-related services. He will be responsible for driving initiatives that improve payer processes, enhance member and provider experiences, and optimize cost and efficiency. Also he will work closely with executive leadership and healthcare partners to ensure the organization remains competitive and compliant in a rapidly evolving industry. 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.