Manager-Health Plan Operations
Manager-Health Plan Operations
Posted on :
20-12-2024
Employer Active
1 Vacancy
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Job Description
Our client is seeking a Health Plan Operations Leader to oversee key functions such as TPA/BPO management claims utilization management and pharmacy services. This role requires strong leadership skills and knowledge of Medicare and Medicaid regulations. The successful candidate will play a vital role in transforming how older adults receive care allowing them to age comfortably at home and in their communities.
Key Responsibilities
Lead Health Plan Operations ensuring staff are trained and equipped to deliver on organizational goals
Manage vendor oversight for key vendors such as TPA/BPO PBM and pharmacy services
Oversee all Medicare Part D operations including reporting compliance and audits
Develop processes to maintain participant Medicaid & Medicare eligibility
Collaborate across departments to support authorizations billing claims and appeals processes
Lead collaboration and education across all teams to enhance understanding of Health Plan services
Manage enrollment and disenrollment activities ensuring compliance with regulatory requirements
Oversee enrollment data management and data systems coordinating with vendors to meet program requirements
Manage workflows related to selfpay and private billing processes in collaboration with accounting and TPA/BPO
Collaborate with analytics teams to monitor claims processing enrollment reconciliation and Part D activities
Lead operations by providing care teams with tools and processes for efficient decisionmaking
Assist with government relations activities and collaborate on regulatory audits such as CMS and State reporting
Support reinsurance activities and collaborate with the Finance team on key reporting requirements
Oversee access to online systems and portals ensuring Health Plan Operations are compliant and data is secure
Continuously seek improvements to processes and systems as the organization grows and increases in complexity
Build mentor and manage teams supporting various Health Plan Operation functions
Communicate confidently and persuasively with internal and external stakeholders to ensure clarity and transparency
Embrace additional opportunities and responsibilities as needed actively participating in the continued growth and success of the organization
Schedule and Shift Details
Monday Friday 8a5p. Hybrid role supporting Greater Los Angeles and South Los Angeles Markets
Travel
Up to 40% travel required
Benefits:
401k with Employer match
Your choice of 6 medical plans with premium coverage of up to 80% for employees and 75% for all dependents
Dental vision health savings account flexible spending accounts short and longterm disability coverages
PTO starting at 20 days per year; plus 12 paid holidays per year and 2 floating holidays per year
Generous CME/CEU budget and time off and professional development opportunities
Onetime stipend towards setting up your home office (for remote or hybrid roles)
Family friendly policies including paid new parent leave!
qualifications
required- Bachelors degree or higher
- 4 years of experience in ALL of the following:
- Health Plan Operations
- Medicare D Operations
- TPA/BPO management
- 3 years of experience in ALL of the following:
- Vendor Management
- Data and Systems Management
- Utilization Management
- Enrollment Oversight
management,data,leadership + management,communication,adaptation,professional conduct,operations
Employment Type
Full Time
Company Industry
Key Skills
- ERP Sales
- Hotel Reception
- Loans
- Accident Investigation
- Fire Alarm
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