Vice President, Medicare Operations

Description

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.  

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

The Vice President of Operations is responsible for leading and overseeing key operational areas of the Medicare health plan. Ensuring efficiency, compliance, and execution in Member Services, Grievance & Appeals, Enrollment, Claims Operations, Configurations, and Credentialing department. Reporting to the Chief Operating Officer (COO), the VP Operations will be responsible for enhancing the internal organization processes and infrastructure that will allow Clever Care Health Plan to grow and fulfill its mission.

Functions & Job Responsibilities

• Provides leadership, direction, Medicare expertise, and skill development to the plan's operating team, outsourced vendors, report & analytics, and Information Technology (IT).
• Ensures appropriate prioritization of initiatives and good resource management to fulfill program goals. Facilitates data-driven decision making across the organization that leads to meaningful actions.
• Leads the integration and oversees all internal operations to promote compliance, Five Star success, administrative excellence, and growth of the organization.
• Enhances the effectiveness and quality of Clever Care’s programs and services by facilitating communication and developing and leading cross-functional teams to address specific objectives and deliver on goals; ensures accountability as well as measures of success,
• Oversight of operational work plans, workflow processes and business plans for each functional area. Responsible for oversight of business continuity and disaster planning.
• Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.
• Ensure the delivery of high-quality, culturally competent service that meets or exceeds CMS requirements and member expectations while working collaboratively with business users to mitigate risk.
• Direct enrollment and eligibility processes to ensure accuracy, compliance, and seamless onboarding of new members.
• Oversee Claims Operations and Configuration Information Management and works collaboratively with internal departments to ensure the health plan processes for claims and encounters, aligns with regulatory requirements for each applicable line of business
• Oversee the Member Appeals and Grievances process, completes analytics to identify trends and execute strategies to improve member satisfaction.
• Ensure a robust and efficient credentialing process for providers, maintaining compliance with all regulatory and accreditation requirements
• Work closely with internal stakeholders to develop and execute effective member retention strategies to achieve desired retention goals.
• Maintain strict adherence to Medicare Advantage regulatory requirements, partnering with compliance and legal teams to address any issues
• Support the COO with operationalizing annual business plan; fosters operational innovation and ensure high standards of performance and consistency with Clever Care Health Plan core values.
• Strategically leverages the organization’s resources in support of its mission and goals, contributing to the financial integrity and sustainability of the plan.
• Responsible for direct and indirect report’s employment life cycle including hiring, termination, performance management, and employee development. Provides coaching to improve performance and holds regular development discussions with direct reports.
• Sets clear goals and objectives and uses metrics to measure performance and hold staff accountable. Communicates and cascades information to employees in a timely manner and actively participates in the success of cross-organizational programs and initiatives.
• Directly responsible for operational issues within Clever Care Health Plan, with wide latitude for independent decision making, within the framework of delegated authority. Customers include department heads, senior management, vendors, governmental agencies, and other outside agencies.
• May require off-site travel

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values
• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining and sharing exciting possibilities
• Enlist others in a common vision by appealing to shared ambitions

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve
• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships
• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence
• Celebrate the values and victories by creating a spirit of community
   

Qualifications

Qualifications

Education/Experience:

• Bachelor’s degree required. Master’s preferred
• Ten (10) years’ experience in managed care
• Five (5) years in Medicare Advantage operations leadership

Skills:

• Seasoned leader with experience managing/supervising employees. The ability to motivate and encourages staff; leads through change and adversity.
• Exceptional coaching, mentoring, and people development skills
• Analytical and critical thinking skills are required to integrate and interpret data from diverse sources.
• Demonstrated adaptability and flexibility to change and to new ideas and approaches.
• Strong knowledge of current CMS and Department of Managed Healthcare regulations governing Medicare Advantage products and experienced at interfacing with national and regional CMS offices.
• Strong executive presence and presentation skills
• Strong focus on people to develop a team and operate in a highly collaborative environment.
• The candidate must have excellent organizational skills with superior written and verbal communication skills.
• The candidate also must exhibit initiative and ability to assume responsibility, prove initiative and maintain confidentiality, as well as demonstrate comfort working in a complex, competitive environment.

Wage Range: $194,000.00 - $248,000.00

Location: Remote, must be willing to travel 1-2 times per quarter

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

Salary : $194,000 - $248,000