Job Description :
Dear Candidate,

We are looking for AVP Claims in New York,
Duration- Fulltime

Complete responsibility of all aspects of claims operations, reporting into CIO.


· Design and develop Claims Operations strategies and work with software / IT vendors, staff and department managers to execute claims processing and servicing activities

· Lead Claims Operations on external matters, such as, regulatory audits and external communication, as well as internal matters, such as, implementations and issue resolution involving across departments.

· Strategize, plan, build team, , and lead the claims related operations of health plans.

· Lead Claims Configuration domain to ensure proper configuration (e.g., benefits, fee schedules, etc and the ongoing setup of providers, contracts, etc. in the claim system.

· Lead the Claims Inventory function to ensure fast & accurate processing of claims, while being in compliance with organizational goals and regulatory guidelines.

· Lead Claims Services domain to ensure the effective handling of provider inquires across multiple incoming channels, fast resolution and the highest level of customer satisfaction.

· Manage the Claims Integrity activities to ensure the consistent encounter reporting to Federal and State agencies, accurate auditing of claims processing results.

· Assure operational excellence and internals as well as regulatory compliance.


· Required: Undergraduate degree in Health, Business Administration or related field.

· Preferred: Graduate Degree in Health, Business Administration or related field.

Mandatory Knowledge and Skills:

· 7+ years’ experience in Managed Care and/or Healthcare Administration

· 5+ years working experience supervising/ managing employees.

· Skills and experiences in implementing systems, processes and procedures for operational excellence

· Demonstrated ability to create, adapt and propagate organizational changes.

· Ability to effectively interact team and/or matrix environment.

· Strong knowledge of Claims and related Operations in the healthcare insurance industry

· Strong organizational, verbal and written communication skills.

Preferred Knowledge and Skills:

· 5+ years’ of hands-on experience in Claims Operations, Processes, procedures and Regulatory Aspects.

· Deep domain knowledge of government programs (Medicare Advantage and Medicaid) related Claims Operations in managed care.

Job Description