AVP, Claims Operations

Purpose:

The UPMC Health Plan is seeking an accomplished health insurance executive to lead a large, complex claims organization, driving greater efficiency, accuracy, automation, and cost effectiveness while maintaining the highest standards of compliance, quality, and service.

The Associate Vice President (AVP), Claims Operations is an executive responsible for leading the strategic and operational performance of the health plan's claims administration function. This position provides executive oversight for end-to-end claims processing operations, including claims adjudication, adjustments, configuration support, payment integrity partnerships, operational excellence, quality assurance, and regulatory compliance.The AVP is accountable for ensuring accurate, timely, and compliant processing of medical, behavioral health, and ancillary claims while balancing financial stewardship, provider satisfaction, member experience, and organizational performance objectives. Working closely with executive leadership, this role drives operational transformation, workforce development, automation initiatives, and enterprise claims strategies that support growth and long-term organizational success.

This position is based in Downtown Pittsburgh.

Responsibilities:

• Executive Leadership
  • Contributes to the establishment and execution of the strategic vision for claims operations across all lines of business.
  • Develop organizational objectives that align with enterprise goals, regulatory requirements, and customer expectations.
  • Provide leadership for multiple operational departments and geographically dispersed teams.
  • Serve as an advisor to executive leadership regarding claims performance, operational risks, industry trends, and strategic opportunities.
• Claims Operations Oversight
  • Provide oversight of claim processing functions, including adjudication, adjustments, inventory management, workflow optimization, and payment accuracy.
  • Ensure operational performance consistently meets or exceeds established service level agreements and regulatory requirements.
  • Maintain accountability for claims production, inventory management, quality performance, backlog reduction, and operational productivity.
  • Oversee implementation of operational best practices that improve efficiency and service delivery.
• Regulatory, Compliance & Risk Management
  • Ensure organizational compliance with CMS, state insurance regulations, accreditation standards, contractual obligations, and internal policies.
  • Direct audit readiness activities and support regulatory reviews, client audits, and accreditation surveys.
  • Oversee risk management initiatives related to claims processing operations.
  • Partner with Legal, Compliance, and Enterprise Risk departments to identify and mitigate operational and financial risks.
• Operational Excellence & Transformation
  • Lead operational improvement initiatives focused on automation, workflow redesign, and productivity enhancement.
  • Utilize performance analytics to identify trends, root causes, and opportunities for operational improvement.
  • Sponsor continuous improvement programs utilizing Lean, Six Sigma, and process improvement methodologies.
  • Drive automation and system enhancement strategies that increase first-pass resolution and reduce manual intervention.
• Financial Stewardship
  • Accountable for operational budgets, staffing strategies, vendor expenditures, and administrative cost management.
  • Partner with Finance, Actuarial, and Payment Integrity teams to improve payment accuracy and cost effectiveness.
  • Ensure claims operations support accurate financial reporting and reserve processes.
  • Balance operational efficiency with quality, compliance, and customer satisfaction objectives.
• Talent Strategy & Organizational Development
  • Build and sustain a high-performing leadership team through succession planning, coaching, mentoring, and leadership development.
  • Establish workforce strategies to support organizational growth and operational scalability.
  • Foster a culture of accountability, engagement, innovation, and continuous improvement.
  • Lead change management efforts associated with major business and technology initiatives.
• Vendor & Business Partner Management
  • Provide executive oversight of third-party administrators, repricing vendors, technology partners, and operational service providers.
  • Establish performance expectations and governance processes for key vendor relationships.
  • Collaborate with Provider Services, Customer Service, Medical Management, Appeals, Enrollment, Information Technology, and Finance to achieve enterprise objectives.