Manager Health Plan Operations

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Job description

Manager of Health Plan Operations career opportunity with our healthcare client in Los Angeles, CA.

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.

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 dis-enrollment activities ensuring compliance with regulatory requirements

Oversee enrollment data management and data systems coordinating with vendors to meet program requirements

Manage workflows related to self-pay 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 decision-making

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

Requirements:

Bachelor's 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 Vendor Management, Data and Systems Management, Utilization Management and Enrollment Oversight

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 long-term 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

One-time stipend towards setting up your home office (for remote or hybrid roles)

Family friendly policies, including paid new parent leave

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