3-5 years of experience
Concerned about your lack of experience? Learn More...
Employment Type:
Full time
Job Category:
Health Care Provider
Executive Director of Operations - Healthcare
(This job is no longer available)
AMI Network | San Francisco, CA
Grad Date

Not sure what types of jobs you are interested in?

Explore Jobs
Based on Your Education

Follow This Company

Job Description

One of our most reputable clients has an opening for an Executive Director of Operations in the Bay Area, a few miles East of San Francisco. The Executive Director is a member of the Accountable Care leadership team with primary responsibility for operational oversight and product management of the Health Plan and Medical Group.

The feedback we've gotten from the other leaders we've helped to get hired here is that they have a unique combination of a close-knit collaborative team, but the resources of one of the larger organizations. They have recently experienced massive growth, adding multiple lines of business in the last three years, so there's the buzz of energy and excitement of a start-up.

This role directly or indirectly oversees all functions required to operate and grow a DMHC and CMS regulated health plan. In addition to managing the staff of the health plan and coordinating work processes with the various Shared Services (e.g., network, claims, finance, etc.), the role interacts closely with the Provider community, the Broker community, regulators, and customers. The role is highly involved in the strategic planning for this product including pricing, benefit design, marketing as well as expense management.

  • Plans and executes the Marketing Campaign and for the Annual Enrollment Period.
  • Responsible for all Sales Planning and Execution, in line with established goals.
  • Develops pricing for both individual and employer group based products.
  • Prepares and submits the annual bid required by CMS.
  • Manages the Medicare STARS rating process.
  • Responsible for all Compliance, including DMHC and CMS reporting and audit preparation.
  • Ensures the effective and efficient operations of the program, including Premium Billing, Appeals and Grievances, Vendor Management, Policy and Procedure Documentation, Fulfillment Processes.
  • Establishes and maintains the Internal Communication of program status with Senior Leadership.

Job Qualifications:

A minimum of Ten (10) years of managed care experience; including a management position with a health insurance company operating a Medicare Advantage health plan. This experience must include direct or indirect management of finance, sales, network and medical management, compliance, operations for a Medicare Advantage health plan.

Knowledge of:

  • Managed Care Sales Process and Channel Distribution Management
  • Medicare Advantage Part D (MAPD) Operations, Part C and Part D
  • Claims Adjudication Processes, Network Contracting and Management
  • Compliance with both state and federal regulations for a Medicare Advantage health plan.
  • Capitation Processes, MAPD Risk Adjustment
  • Performance measurement and incentive programs mandated by CMS and Medicaid Services for Medicare Advantage health plans.

Ability to:

  • Oversee the Sales and Marketing cycle in conjunction with Annual the Enrollment Period
  • Oversee the Annual Bid Process, leading to Pricing and Benefit Structure
  • Ensure Part C and Part D Operations are documented and compliant with CMS and DMHC requirements
  • Understand MAPD Financial Statements and associated Regulatory filing requirements
  • Partner with the Shared Services (Network, Medical Management, Finance, etc.) that are instrumental to MAPD execution
  • Oversee the Risk Adjustment process

Final salary is per employer discretion and commensurate with experience.

About the Company

As healthcare recruiters we recognize that there is a shortage of good people in the healthcare industry. Today it is essential to utilize the efforts of a professional healthcare recruiter that can offer a creative sourcing procedure while being cost effective.

Our team of healthcare recruiters has access to, and strong relationships with, a broad spectrum of healthcare talent both in clinical and healthcare operations. We meticulously search and maintain contact with the very best people in the healthcare industry. We have a large referral network, a successful website and a proven track record of finding and placing the best available candidates.

More importantly, the best candidates know how to find us! Candidates refer us to their friends and colleagues and as such, our candidate pool is a dynamic database that changes every single day.

All Jobs at AMI Network


Applicants must be eligible to work in the specified location