Director, Health Plan Operations (Claims) Florida
On-site · Miami, Florida, United States
Job Summary
Directs and leads a team responsible for the development and administration of state health plan operational functions across Medicaid, Medicare, Marketplace, CHIP, and Medicare-Medicaid Plan (MMP). Oversees claims operations, configuration information management, provider network administration, credentialing, and provider issue resolution; collaborates with COEs and senior leadership to align operations with regulatory requirements and performance goals. Drives provider and member service strategies to improve access and satisfaction; ensures enrollment and support-center operations comply with health plan requirements; supports member retention and community-outreach initiatives; manages stakeholder communications through member portals and CRM tools; hires, trains, and develops staff to achieve department goals.
Required Qualifications
- At least 8 years of health care operations, health care administration, and/or provider services experience, or equivalent combination of relevant education and experience.
- At least 3 years of management/leadership experience.
- Advanced experience with Medicare, Medicaid, and Marketplace plans.
- Experience with prompt pay laws.
- Advanced claims-related experience.
- Demonstrated adaptability and flexibility to change, and to new ideas and approaches.
- Strong organizational and time-management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
- Ability to work cross-collaboratively across a highly matrixed organization and establish and maintain effective relationships with internal and external stakeholders.
- Project management experience.
- Excellent verbal and written communication skills.
- Microsoft Office suite proficiency (including Excel), and applicable software programs proficiency.
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