Vice President of Health Plan Operations and Claims

Responsibilities: This position requires relocating to Ontario, California. The Vice President of Health Plan Operations and Claims is responsible for the development and execution of Claim Operations strategies, end-to-end Claim process automation, optimization and management, identifying and leveraging technology and data to improve the quality and minimize process cost of Claims for all Prime Healthcare's self-insured Employee Health Plans. Through in-depth audit and review of Claims data, the VP will identify financial savings across all aspects of the Employee Health Plans. The VP of Health Plan Operations and Claims will provide strategic leadership and development of the Claims Department and its employees, as well as collaborate with Network Development, Provider Affiliation and Member Relations, Contracting, and Benefits Administration to ensure data integrity and to drive financial and operational value across Employee Health Plans to maximize benefit coverage while containing cost. The VP of Health Plan Operations and Claims will partner with local C-Suites and Hospital Administration to execute goals and plans of the Employee Health Plans. Through inter-professional collaboration, The VP will ensure that TPA and Health Plan are notified in a timely fashion of any changes in process or procedures which would impact their functions. We're looking for someone with operations experience with self-funded health plans including designing operational improvements, performance management techniques and metrics. Someone with significant claims experience including PDR's, Disputes, Appeals and Recoveries. Sound intriguing, then you will be thrilled to know we offer very competitive compensation and amazing benefits. As you would expect, this role has many facets including Health Plan Operations, Health Performance Metrics, Cost Reduction, Market Forces, Quality and Delivery of Care, Regulatory Reforms, Strategy and Operating Models, Long Term Business Objectives, Healthcare Payers, Claim Operations Strategies, Claim Process Automation, Self-Funded Plans, and Employee Health Plans.

Required qualifications: Master's Degree in Business Management, Healthcare Administration, or other relevant fields. A minimum of seven (7) to ten (10) years prior work experience in Claims Operations and Health Plan Strategy, in a Managed Care, Self-Funded or hospital setting is required. Analytical skills with emphasis on generation and utilization of data to drive operational and financial performance. Ability to work in a complex, rapidly evolving environment with multiple internal and external entities and boundaries. Strong interpersonal skills, problem solving and project/time management essential. Ability to develop presentations to all levels using Microsoft Office applications. Strong knowledge of medical coding (ICD-10, HCPCs/CPT, etc.)

Preferred qualifications: Certified Professional Coding Certification, AIC, ARM, or equivalent. Familiarity with multiple Business Intelligence software systems and daily usage of at least one.#LI-TS2At Prime #Healthcare, our employees #wellness is important. We're looking for our next #healthcareleaders or #healthcareprofessionals to guide our #healthplan. This position should be a part of your #jobsearch, we're #hiring and this is a rewarding #jobs.

Pay Transparency: Prime Healthcare Management, Inc. offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $150,000.00 to $250,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire and will be dependent on a wide range of factors, including but not limited to geographic location, skill set, experience, education, credentials, and licensure. Additionally, employees in this position may be eligible to participate in the Company's annual discretionary bonus program. Discretionary bonuses, if any, are based on a number of factors, which include but are not limited to individual and Company performance. Employment StatusFull TimeShiftDaysEqual Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: Privacy Notice Privacy Notice for California Applicants: Job Summary

Location: US-CA-OntarioID: 2026-245189

Category: Executive

Position Type: Full Time

Shift: Days

Job Type: Exempt