Director, Health Plan Operations (Must reside in Florida)
Remote · Miami, Florida, United States or US
Job Summary
Director leads and directs a team responsible for the development and administration of state health plan operational functions, programs and services, ensuring operational effectiveness, contractual compliance, and alignment with member satisfaction, retention, quality, and financial goals. The role collaborates across claims, enrollment, provider data management, credentialing, COEs, and support centers to optimize provider networks, regulatory compliance, and client experiences. Must be able to work remotely from Florida and lead cross-functional efforts for Medicaid, Marketplace, and other health plan lines of business. Key responsibilities include planning, staffing, and coordinating health plan operations; developing provider and member service strategies; overseeing claims operations and data management; ensuring enrollment and support center compliance; managing provider credentialing and issue resolution; supporting member retention and stakeholder experience initiatives; and leading a team through hiring, training, and performance management.
Required Qualifications
- At least 8 years of health care operations, health care administration, and/or provider services 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
Desired Qualifications
- At least 8 years of health care operations, health care administration, and/or provider services 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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