The Day Job of a COO in a Health Plan: Managing Core Applications and Operations By GHIT Digital
Running a modern health plan is not just about strategy—it’s about execution. The Chief Operating Officer (COO), EVP, or VP of Applications in a payer organization carries the responsibility of ensuring that daily operations, member services, and core applications run seamlessly. This role sits at the intersection of business, technology, compliance, and member experience, requiring a blend of operational rigor and strategic foresight.
Core Responsibilities of a Health Plan COO
- - Managing Core Applications: The COO ensures enrollment, eligibility, benefits configuration, care management (UM, CM, DM), provider lifecycle management (PLM), claims, CRM, HRM and ITSM applications are reliable, integrated, and optimized.
- - Overseeing Healthcare LOBs: Health plans operate across Commercial, Medicare, Medicaid, PBMs, TPAs, and more. The COO ensures operations scale without silos across these lines of business.
- - Leading System Implementations & Conversions: From vendor management to data conversions, interoperability, and compliance initiatives, the COO oversees complex system transformations.
- - Partnering with Senior Leadership: The COO collaborates with CEO, CIO, CFO, and CMO to align IT with strategy, manage enterprise risk, and build a succession pipeline.
KPIs that Define Success
- • Operational Efficiency – Claims first-pass adjudication rate, provider onboarding time, call center resolution speed.
- • Financial Performance – Medical loss ratio (MLR), administrative cost ratio, claims leakage reduction.
- • Regulatory Compliance – CMS audit scores, HIPAA compliance, state Medicaid reporting.
- • Member Experience – CAHPS scores, NPS, grievance turnaround time.
- • Provider Satisfaction – Portal adoption, credentialing cycle time, dispute resolution.
- • Technology Stability – System uptime, ticket resolution time, scalability for peak enrollment.
The Strategic Day Job: Balancing Operations and Innovation
While day-to-day operations dominate, today’s COO must also look forward—deploying AI & automation, leveraging low-code platforms like TriZetto – Facets, HealthEdge, Plexis, CRM – Salesforce, ITSM – ServiceNow, Care Management – ZOmega, driving cloud interoperability, and ensuring member-centric engagement etc.
Closing POV – GHIT Digital’s Lens
At GHIT Digital, we view the COO’s office as the operational command center of a health plan. Success is not about keeping the lights on; it’s about orchestrating applications, people, and processes to deliver value—across members, providers, regulators, and shareholders alike. By combining AI-powered, Low-Code platforms with deep payer domain expertise, GHIT Digital partners with health plans to modernize operations, reduce costs, and future-proof the COO’s mandate.
Hashtags
#HealthPlans #HealthcarePayers #COO #HealthcareOperations #DigitalTransformation #CoreApplications #CareManagement #ClaimsAutomation #ProviderLifecycle #EnrollmentEligibility #LowCode #NewgenOne #GHITDigital
