Senior Vice President, Claims Services – Solutions

This is a fully remote position, open to applicants in California, +1 more state.

📋 Description

• Develop and expand a high-performing, multi-client claims operational framework from the point of claim receipt to final resolution.

• Foster operational excellence in areas such as quality, turnaround time, productivity, pending claims, inventory management, backlog, workforce readiness, and adherence to client service-level agreements.

• Spearhead initiatives aimed at operational turnaround and stabilization in complex or underperforming claims settings.

• Enhance proactive quality assurance, auditing practices, root-cause analysis, coaching, release controls, and quantifiable error reduction.

• Implement governance for claims rules, manage operational knowledge, maintain version-controlled client instructions, and establish single-source-of-truth practices.

• Collaborate with Technology and Product teams to outline requirements for workflow, routing, dashboards, audit tracking, knowledge access, release controls, automation, and AI-driven quality processes.

• Lead executive client interactions, encompassing QBRs, governance meetings, escalations, renewal support, recovery discussions, and operational assessments.

• Work alongside Sales, Account Management, and Client Services on discovery, RFPs/RFIs, staffing models, pricing strategies, SOWs, finalist presentations, and opportunities for expansion.

• Manage financial and operational performance, including budget oversight, labor utilization, productivity economics, cost of quality, margin enhancement, and investment recommendations.

• Build, mentor, and develop a claims leadership team that can support growth and fulfill client commitments.

⛳️ Requirements

• Over 15 years of progressive experience in healthcare payer claims, covering claims processing, adjudication, complex claims management, quality, productivity, service levels, and operational performance oversight.

• More than 10 years in leadership roles within claims operations, claims services, claims delivery, or claims transformation in a healthcare payer BPO, outsourcing, managed services, BPaaS, payer administrative services, or a similar client-services framework.

• Proven track record of enhancing quality, decreasing backlog and aging claims, boosting productivity, stabilizing operations, and restoring client confidence.

• Comprehensive ownership of the end-to-end claims process, including intake, assignment, workflow management, pending claims, QA, release governance, reporting, escalation, and final resolution.

• Experience in executive-level client relationship management, covering governance meetings, QBRs, steering committees, executive escalations, renewal support, and recovery discussions.

• Background in supporting growth through RFPs, solution design, staffing models, pricing strategies, SOWs, finalist presentations, and client expansion efforts.

• Strong financial and operational management skills, focusing on staffing economics, cost of quality, labor utilization, margin management, and investment trade-offs.

• Capability to translate claims operational requirements into actionable technology, analytics, workflow, automation, and quality-control specifications.

• Significant experience in the California healthcare payer market is essential.

• Practical experience working with California-based health plans, Medi-Cal programs, California managed care organizations, claims administration services, delegated services models, payer administrative services, or similar California payer environments.

🏝️ Benefits

• Opportunity to influence the strategy, operational model, technology roadmap, and client experience for a growing healthcare services organization.

• Executive sponsorship, visibility, and leadership responsibilities.

• Chance to modernize operations, strengthen client partnerships, enhance technology-enabled service delivery, and contribute to company growth.