Health Plan Operations Manager
2 weeks ago
This is an exceptional opportunity for a mission-driven leader to shape and lead health plan operations in a dynamic, integrated care delivery startup. Reporting to the Sr. Director of Health Plan Operations, this role will oversee key functions such as TPA/BPO management, claims, utilization management, medical records, PBM, and pharmacy services, along with day-to-day Medicare Part D activities. As a key member of the Health Plan leadership team, you will ensure sound financial practices and efficient operations, helping us scale responsibly. Most importantly, you 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: Ensure staff are trained and equipped to deliver on organizational goals and maintain operational excellence.
- Vendor Oversight: Manage and provide oversight for key vendors such as TPA/BPO, PBM, and pharmacy services to ensure effective service delivery.
- Medicare Part D Leadership: Oversee all Medicare Part D operations, including reporting, compliance, and audits.
- Eligibility Management: Develop processes to maintain participant Medicaid & Medicare eligibility, resolve issues, and ensure timely data monitoring.
- Collaborate Across Departments: Work with Finance and Care Delivery operations to support authorizations, billing, claims, and appeals processes.
- Cross-Disciplinary Education: Lead collaboration and education across all teams to enhance understanding of Health Plan services.
- Enrollment Oversight: Manage enrollment and disenrollment activities, ensuring compliance with regulatory requirements, and provide continuous training.
- Data and Systems Management: Oversee enrollment data management and data systems, coordinating with vendors to meet program requirements.
- Billing Support: Manage workflows related to self-pay and private billing processes in collaboration with accounting and TPA/BPO.
- Claims and Reconciliation Monitoring: Collaborate with analytics teams to monitor claims processing, enrollment reconciliation, and Part D activities.
- Utilization Management: Lead operations by providing care teams with tools and processes for efficient decision-making.
- Support Regulatory Audits: Assist with government relations activities and collaborate on regulatory audits, such as CMS and State reporting.
- Reinsurance and Finance Collaboration: Support reinsurance activities and collaborate with the Finance team on key reporting requirements.
- Access and System Oversight: Oversee access to online systems and portals, ensuring Health Plan Operations are compliant and data is secure.
- Process Improvement: Continuously seek improvements to processes and systems as the organization grows and increases in complexity.
- Team Building and Mentorship: Build, mentor, and manage teams supporting various Health Plan Operation functions.
- Effective Communication: Communicate confidently and persuasively with internal and external stakeholders to ensure clarity and transparency.
- Contribute to Organizational Growth: Embrace additional opportunities and responsibilities as needed, actively participating in the continued growth and success of the organization.
- This role will be a hybrid role supporting both our Greater Los Angeles and South Los Angeles Markets. This position will require up to 40% of the time in markets as needed to support business needs.
- Schedule is Monday - Friday.
- This position falls under the FLSA Exempt status.
myPlace Health offers a robust compensation package for this role that includes cash compensation and other total rewards. Base pay is based on several factors including but not limited to education, relevant work and industry experience, certifications, and location of the role. Onsite roles include appropriate geographic adjustments, while remote roles are typically priced off national pay data.
Competitive Incentive Plan: Performance-based incentive plan that is beyond the industry standard
Preparing you for retirement: 401k with Employer match
Medical Plans to fit your needs: Your choice of 6 medical plans, with premium coverage of up to 80% for employees and 75% for all dependents
Ancillary benefits to meet your other needs: Dental and vision plans to meet your needs of you and your dependents; health savings account, flexible spending accounts, short- and long-term disability coverages, as well as basic life insurance. myPlace is also proud to offer accident, hospital indemnity, and critical illness benefits for our team.
Generous time off: PTO starting at 20 days per year; plus 12 paid holidays per year, and 2 floating holidays per year
Professional Development top of mind: Generous CME/CEU budget and time off, and professional development opportunities
Making your home office comfortable: A one-time stipend towards setting up your home office, if applicable.
Family friendly environment: Family friendly policies, including paid new parent leave and new child care stipend
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