Assistant Vice President, Medical Claims Operations

Application Deadline: 4 October 2026

Department: Claims Management

Employment Type: Permanent - Full Time

Location: Home United States

Description

Key Responsibilities

• 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.

• 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.

• 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.

• 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.