Assistant Vice President, Medical Claims Operations

The Assistant Vice President leads claims staff and oversees medical excess and reinsurance claims operations and payment integrity activities supporting reinsurers, issuing carriers, managing general underwriters (MGUs), risk-bearing entities, and other excess risk programs. The role is accountable for client service, technical claim oversight, quality assurance, staff development, workflow management, and timely delivery of assignments.

Key Responsibilities

Leadership and Staff Management

• Manage claims staff, including Claims Directors, Claims Examiners, and Claims Assistants, with responsibility for coaching, performance management, workload oversight, and development.
• Assign work, monitor priorities and productivity, to ensure assignments are completed accurately and on schedule.
• Provide training, peer review, feedback, and management coverage as needed.

Client and Account Management

• Oversee assigned client accounts and serve as a senior contact for clients, intermediaries, and internal colleagues.
• Lead communications regarding claim status, findings, deliverables, and issue resolution.
• Review complex or escalated claims and ensure supporting documentation is obtained and maintained.
• Support client retention, account transitions, and business development activities as requested.

Technical Claims Oversight

• Oversee complex Medical Excess of Loss, Provider Excess of Loss, HMO Reinsurance, and Employer Stop Loss specific excess claims and reinsurance matters, including payment integrity reviews, coordination of benefits, high-cost claim investigations, reimbursement disputes, and delegated claims operations for commercial, Medicare Advantage, Medicaid and provider-sponsored health plan populations.
• Review and interpret insurance policies, reinsurance agreements, summary plan descriptions, provider contracts, risk-sharing arrangements, health plan and TPA agreements, and claim data to determine coverage and reimbursement.
• Apply knowledge of medical and pharmacy claims, reimbursement methodologies, medical coding, CMS regulations, and Medicare and Medicaid programs and fee schedules.
• Use internal and external claims systems, including the Claims Adjudication System, to manage claim data and workflows.

Quality and Operations

• Monitor quality standards, maintain review records, and address operational or service risks.
• Prepare or review client reports, savings reports, invoices, and other recurring deliverables.
• Improve claims procedures, controls, reporting practices, and workflow efficiency.
• Collaborate with leadership on staffing, operational planning, and special projects; travel occasionally for audits, projects, or client meetings.

Skills, Knowledge & Expertise

• Seasoned experience (10 years +) of progressively increasing responsibility in medical claims management, managed care claims operations, health plan administration, payment integrity, provider risk management, including employer stop loss and/or medical excess claims.
• Leadership experience managing claims professionals, workflows, quality, and client deliverables.
• Strong knowledge of self-insured plans, managed care concepts and risk sharing arrangements, medical and pharmacy claims, claim processing platforms, relevant contracts, and supporting documentation.
• Working knowledge of CMS regulations, Medicare and Medicaid programs and fee schedules, medical terminology, and coding.
• Excellent leadership, client service, communication, analytical, and problem-solving skills with strong attention to detail.
• Proficiency in Microsoft Word and Excel and the ability to manage multiple priorities independently in a fast-paced environment.

Originally posted on Himalayas