Mass Advantage is a Medicare Advantage health plan, located in the heart of Worcester County, headquartered in Worcester MA. Mass Advantage is owned and designed by UMass Memorial Health providers with their patients’ needs in mind. 

We are seeking a Vice President of Operations a key member of the executive leadership team, responsible for overseeing and driving the operational strategy and execution of the health plan. This role ensures the seamless integration and performance of claims, enrollment, customer service, and vendor management functions while maintaining compliance with regulatory requirements and industry best practices. The VP of Operations will lead cross-functional teams, optimize processes, and deliver operational excellence to support the organization’s strategic goals. 

Strategic Leadership

• Establishes the strategic direction of the company’s operations, including budget, execution, and reporting; executes this strategy in collaboration with company leadership.
• Provides strategic oversight and leadership across all operational functions, including claims, enrollment, customer service, and vendor management.
• Identifies and mitigates operational risks across all areas of responsibility.
• Oversees all third party vendors and executes strategically on behalf of the organization to ensure best practices are being utilized.

Claims Management

• Oversees the claims processing function to ensure timely, accurate, and compliant adjudication of claims.
• Develops and monitors claims performance metrics, ensuring alignments with organizational goals and regulatory requirements.
• Identifies and implements process improvements to enhance claims accuracy and efficiency.

Enrollment Operations

• Directs and oversees enrollment processes to ensure seamless onboarding of members and compliance with regulatory standards.
• Collaborate with internal teams to optimize enrollment workflows and address any system or process gaps.
• Tracks and analyzes enrollment trends to inform strategic decision making.

Customer Service Leadership

• Establishes and enforces customer services standard with vendors and internally to ensure a high level of member satisfaction and issue resolution.
• Monitors customer service performance metrics and implements strategies to improve service delivery.
• Oversee training programs to ensure customer service teams are equipped to handle complex inquiries and escalations.

Vendor Management

• Leads the selection, negotiation, and management of vendor relationships to ensure alignment with organizational goals and service-level agreements (SLAs).
• Monitors vendor performance, addressing any issues or risks proactively to maintain operational excellence.
• Ensures vendors comply with contractual obligations, regulatory requirements, and company standards.

Operational Excellence

• Develops, implements, and enforces key performance metrics, milestones, specifications, documentation and reporting requirements, and budgets.
• Tracks and analyses performance across all operational functions, leveraging insights to drive continuous improvement and successful implementation of company goals.
•  Oversees and facilitates cross-functional projects and teams for Medicare annual bid process, in collaboration with organizational leaders.

Regulatory and Compliance Oversight

• Ensures all operational functions, including claims, enrollment, and customer service, adhere to federal, state, and industry regulations.
• Stays informed of changes in regulatory requirements and implements necessary adjustments to maintain compliance.
• Ensures adherence to company processes, CMS guidelines, procedures, and industry best practices.

Communication and Reporting

• Communicates with colleagues, clients, and other stakeholders to identify and assess product and program requirements; applies this knowledge to support Mass Advantage’s product development strategy.
• Communicates department, program, and project performance and process to senior leadership through periodic status reports and presentations.

* Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Bachelor’s degree in business administration, healthcare management, or a related field required; master’s degree preferred.
• Minimum of 10 years of progressive leadership experience in health plan operations, with at least 5 years in Medicare Advantage Prescription Drug Plan (MAPD) and expertise in clinical operations, pharmacy operations, claims, enrollment, customer service, and vendor management.
• Experience working in a provider-aligned health plan environment strongly preferred.
• Proven track record of managing large-scale operational teams and driving performance improvements.
• Previous experience with CMS Program audits, UM Focused Audits, 1/3 Financial Audits, or Risk Adjustment Data Validation audits and state operational audits. 
• Experience with leading and developing health plan operational teams with a solid track record of delivering return on investments.
• Demonstrated ability to lead cross-functional teams and drive collaboration across departments.
• Strong problem-solving and decision-making skills, with the ability to address complex operational challenges.
• Ability to drive change, influence individuals at all levels, and to take appropriate risks.
• At least ten years of experience in project and program management.
• Excellent verbal and written communication skills.
• Strong analytical and problem-solving skills with a proven ability to improve business processes and practices to reduce costs and increase efficiency.
• Proficiency in operational systems and tools used in claims processing, enrollment, and customer service.
• Ability to analyze data and leverage insights to drive operational improvements.
• Ability to identify and implement best practices and continual performance measurement. 
• Excellent interpersonal and negotiation skills.
• Excellent organizational skills and attention to detail.
• Proficient with the financial tools required to make estimates, business forecasts, and strategic decisions.