Vice President, Claims, Payment Integrity, & Enrollment Operations

CareOregon puts the care in health care. We are a nonprofit providing health insurance services to meet the health care needs of low-income Oregonians. We serve about one quarter of Oregon Health Plan members plus members in our Medicare plan.

Our mission is to inspire and partner to create quality and equity in individual and community health. Our vision is healthy communities for all individuals, regardless of income or social factors.
We focus on the total health of our members, not just traditional health care. In teaming up with members, their families and their communities, we help Oregonians live better lives, prevent illness and respond effectively to health issues.

To apply visit www.careoregon.org/careers and search for Vice President, Claims, Payment Integrity, & Enrollment Operations (19545). If you have any difficulty submitting your resume through the online process, please let us know by emailing recruitment@careoregon.org.

To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.

Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon’s standard accommodation process.

Job Summary
This position is responsible for leading claims operations, payment integrity, and enrollment operations for the organization. Time is focused on enterprise-wide engagement and department oversight. Primary duties include strategic planning and operational effectiveness, as well as development and oversight of resources, relationships, and teams. This position actively and regularly participates in organizational strategic planning and collaboration.

Essential Responsibilities
Technical/Strategic Leadership
• Provides strategic leadership for claims, payment integrity, and enrollment operations.
• Ensures appropriate productivity and quality targets are established, met, and accurately reported on a regular basis.
• Effectively uses business intelligence and data analytics to proactively monitor, forecast, and identify trends in operations.
• Identifies process improvement opportunities and systems solutions to support operations functions and oversees implementation.
• Ensures compliance with federal and state regulatory and contractual requirements.
• Ensures effective sourcing and use of vendor contracted services; leads team in identifying, establishing, and managing vendors; negotiates contracts as needed.
• Regularly identifies new opportunities for automation, analytics, and professional services to improve and support the organization in exceeding production, quality, and financial targets.
• Ensures documented policies and procedures are established and maintained to ensure accurate, efficient, and compliant operations.
• Instills work culture of continuous process improvement, innovation, and quality.
• Remains current with healthcare industry trends, best practices, and approaches to drive efficient and compliant operations.
Strategic Planning
• Leads the development of vision and goals for areas of oversight.
• Defines operational structure for areas of oversight, and approves policies.
• Participates in the strategic planning process for the organization.
• Maintains an enterprise view while establishing business unit priorities.
Financial/Resource Management
• Develops budgets in alignment with strategic planning.
• Ensures teams have sufficient resources to perform their work.
• Ensures budgets are monitored and managed effectively across areas of oversight.
• Approves resource allocations within budget, including people, finances, and timelines.
Relationship Management
• Ensures strategic messages are regularly and effectively relayed to management team and staff; promotes transparency.
• Collaborates with leaders across the organization in identifying integrated improvement strategies and ensuring meaningful integration.
• Represents the organization in external meetings and functions as required providing leadership presence, subject matter expertise, and effectiveness
Supervision
• Directs team(s) and establishes team direction and goals in alignment with the organizational mission, vision, and values.
• Identifies work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens.
• Identifies department priorities; ensures employees have information and resources to meet job expectations.
• Leads the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff.
• Manages, coaches, motivates, and guides employees; promotes employee development.
• Incorporates guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making.
• Ensures team adheres to department and organizational standards, policies, and procedures.
• Evaluates employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action).
• Performs supervisory tasks in collaboration with Human Resources as needed.

Education and/or Experience
Required:
• Minimum 12 years’ experience in health care operations, insurance, or related areas, including at least 3 years’ experience in claims payment integrity
• Minimum 5 years’ experience managing people
Preferred:
• Experience overseeing Medicaid managed care and Medicare operations, including claims payment integrity, enrollment, and billing
• Experience in a senior management capacity for a mid to large-sized regional or national managed care organization
• Experience with dental, pharmacy, transportation, and behavioral health benefits a plus

CareOregon is among the top-rated nonprofits in Oregon, noted especially for our work/life flexibility. We offer competitive salaries and generous benefits.

Salary will be discussed during the interview process.

Position Description »