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Manager/Senior Manager, Health Plan Operations

myPlaceHealth · 30+ days ago
Negotiable
Full-time
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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.

What does success look like?

  • 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.

Additional Information

  • 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.

Last updated on Oct 4, 2024

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